WC Form 18 Revised 12/00
EMPLOYER'S APPLICATION FOR SELF INSURANCE (Submit one completed copy) CONFIDENTIAL To the DEPARTMENT OF INDUSTRIAL RELATIONS: The undersigned, an employer subject to the provisions of the Alabama Workers' Compensation law, as last amended, hereby applies for the privilege of self-insuring the payment of compensation provided in that law, and submits the following facts under oath to the Department of Industrial Relations to enable it to determine if sufficient financial ability exists to render certain the payment of such compensation: 1. Name of Applicant 2. Address
(Number) (Street) (City or Town) (County) (State) (Zip)
(Number) (City or Town) (State) (Zip)
ALA U.C. Number EMPLOYER IDENTIFICATION NUMBER
3. The applicant is
(State whether individual, co-partnership, limited partnership, corporation, receiver or trustee)
4. Describe briefly the general character of the operations performed and the articles manufactured or compounded at or away from the plant or premises of the applicant.
5. Description of employment:
Location of Plant or Plants Kind of Equipment Estimated average number Estimated average number Estimated payroll of all of employees at all points of employees in Alabama Alabama employees for ensuing year
6. If a Corporation or Limited Partnership list below names of officers, directors, and residence of each:
NAME OFFICIAL TITLE ADDRESS
7. If a Limited Partnership, give date of formation and duration
8. If a Partnership, list below names of members and residence of each
9. If Individual, give name and residence
10. If a Corporation, answer the following: Chartered under the laws of the State of Date of incorporation_____________________ Authorized Capital Stock: (Common) $_______________ (Preferred) $ 11. Is applicant a subsidiary?________ Give name and address of parent company___________________________
(Subsidiaries must have separate applications and indemnity agreements)
12. If foreign corporation, give address of Home Office_________________________________
13. Date when self-insurance is desired______________________________20_____12:01 a.m. 14. Are you now complying with Section 25-5-8 of the Law, by carrying workers' compensation insurance on your employees? If so, indicate the name of the insurance company (not local agent) with whom you are insured.
15. What is the expiration date of your present policy?__________________________________ 16. Are you now, or have you been within the past three years, an assigned risk for workers' compensation insurance? (Give dates and details on separate page, if necessary) 17. As a self-insurer, will you deal directly with your employees in workers' compensation matters, or through an approved service organization? If the latter method is to be used, give name and address of the organization.
18. Past three-year Accident Experience: Number of deaths Alabama Workers' Compensation Premiums
___________ ___________ $__________
____________ ____________ $___________
____________ ____________ $____________
Alabama Workers' Comp Incurred Losses
19. Are there any outstanding unpaid judgments subject to execution rendered against the applicant under the provisions of the Workers' Compensation Law, as last amended? (Give amounts and details on separate page, if necessary)
20. Applicant must attach audited or certified financial reports for the prior three years of operation. 21. Applicant must submit a $500.00 application fee with each application submitted. Make payable to: Department of Industrial Relations Workers' Compensation Administrative Trust Fund.
22. Name of excess insurance carrier (if any) Amount of Retention $ 23. Relate facts, covering past three years: Year Ending 20 20 20 Sales (Omit cents) Expenses (including payroll) Payroll Profit or Loss (Specify) Specific, Aggregate, or both?
24. Has the applicant, or its parent corporation, every filed for bankruptcy? separate sheet. AGREEMENT CONDITIONS 25. In consideration of the approval of this application, the applicant expressly agrees:
If yes, give details on
That this privilege may be revoked at any time in the discretion of the Director of Industrial Relations as provided in Section 25-58(d1) of said Law, as amended. That the applicant will promptly furnish adequate hospital, medical, surgical, and burial benefits within the limits of the Law. That the applicant will discharge liability for compensation to injured employees or their dependents in accordance with said Law's requirements. That reports will be promptly furnished the Department in strict accordance with Sections 25-5-4, 25-5-5 and 25-5-7 of said law. That the applicant will not solicit, receive or collect from his employees, any part of the cost to him of operating under this Law. That the applicant will promptly notify the Department upon insuring his workers' compensation liability with a private casualty insurance company, thereby cancelling his self-insurance privileges. That a copy of the company's annual report, or statement of assets and liabilities, will be mailed to the Department at the close of each fiscal year, as evidence of continued financial ability to self-insure its liability under said Law.
(d) (e) (f)
(Signed)________________________________________ (Title)__________________________________________ STATE OF ________________________________ COUNTY OF ______________________________ __________________________________, being first duly sworn, appeared personally and declared that the facts set forth in the foregoing application are true to the best of his knowledge, information and belief. Subscribed and sworn to before me, this __________ day of __________________________, 20_____ _____________________________________
(SEAL) My commission expires on the __________ day of _________________________, 20_____