Free K-WC 120 - Application for Self-Insurance (Rev. 02-07) - Kansas

Division of Workers Compensation

APPLICATION FOR SELF-INSURANCE

____________________________________________________________ ___________________ ___________________ ApplicantOrganizationName DateofApplication PermitNumber herebyappliesfortheprivilegeofbeingaself-insurerundertheKansasWorkersCompensationActandsubmitsthefollowing reportinsupportofsaidapplication. All Questions Must Be Answered - If Not Applicable - put N/A 1. Addressofprincipaloffice:____________________________________________________________________________ 2. Applicantis: Individual Partnership Corporation PublicAuthority

3. Applicant'sgeneralofficers,partnersorpublicofficials: Name/Title BusinessAddress

__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ 4. Dateapplicant'sbusiness/publicauthoritycommenced:________________________________________________________ 5. Personresponsibleforself-insuranceprogram: _________________________________________________________________________________________________ Name Title TelephoneNumber ___________________________________________________________________________________________________________ AddressofResponsiblePerson(if different from item 1 above) 6. Servicecompanyinformation a. Losspreventionservices: (1) Nameofservicecompany_________________________________________________________________________ (2) Addressofservicecompany_______________________________________________________________________ (3) Telephonenumber_______________________________________________________________________________ (4) Contactperson_________________________________________________________________________________ (5) Givedetailsofservicesfurnishedbyservicecompany___________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

K-WC 120 (Rev. 2-07)



b. Claimshandlingservices: (1) Nameofservicecompany_________________________________________________________________________ (2) Addressofservicecompany_______________________________________________________________________ (3) Telephonenumber_______________________________________________________________________________ (4) Contactperson_________________________________________________________________________________ (5) Givedetailsofkindsofservicesthatwillbefurnishedbyservicecompany___________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

IfyouDONOTplantouseanadjustingcompany,pleaseexplainonaseparateattachmenttheplanyouhaveforadjustingclaims foryourcompany.Suchexplanationshouldincludethenameofthepersondirectlyinchargeoftheadjustingactivity.Explain whatprocedureyouplantofollowinregardtoinvestigatingandadjustingclaimsandwhetherthoseindividualsadjustingclaims willbeexclusivelyengagedinthatactivity. TheDivisionofWorkersCompensationmayrequiretheuseofanadjustingcompanyifwedonotfeelthatyourin-houseadjusting procedurewouldbeadequatetoservetheinjuredworkers. DOTHEABOVE5.AND6.(a)AND(b)HAVEAWORKINGKNOWLEDGEOFTHEKANSASWORKERSCOMPENSATION ACT? Yes No 7. Safetyprogram a. Personincharge____________________________________________________________________________________ b. Please furnish a copy of the engineering report which gives a description of the risks operations from raw material receivedtofinishedproductandengineer'sevaluationofthesafetyprogram. Ifunavailable,acopyofyoursafetymanualwillbeacceptable.Ifpreviouslyfiled,onlychangesneedtobesubmitted.

c. Whenwerepremiseslastinspected?____________________________________________________________________ Inspectingagency__________________________________________________________________________________

8. Medicalandhospitalcare a. Doyouemployafullorpart-timedoctor? Yes No

Name__________________________________________________________________________________________

b. Whereareinjurednormallysent?____________________________________________________________________ c. Doyouhaveahospitalintheplant? Firstaidroom? Yes No Yes No Yes No

Professionalnurseonpremises?

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9. Losshistory(5 years)instateofKansas(NEW PERMIT APPLICATIONS ONLY) LiabilityPeriod From To Gross Payroll Total Losses Paid Losses Reserves NationalCouncil onCompensation Experience Modification

10. ivethefollowinginformationregardingthestateofKansas:(If more space is needed, use separate page.) G *W.C. CodeNo. *Classification Numberof Employees EstimatedAnnual GrossPayroll *Current ManualRates Manual Premium

*Generallyavailablefromyourinsuranceagentorexcesscarrier.UsethecurrentapprovedAssignedRiskRates. Theseratesaremeasurableformanualpremiumdetermination. Totalestimatedannualgrosspayroll:____________________________________ TotalnumberofemployeesinKansas:___________________________________ Total estimated manual premium: _____________________________________ 11. ForthestateofKansas,indicatetheworkers'estimatedaverage weeklywageatyourcompany(exclude clerical and executive wages):

$____________________________________

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12. ExcessInsuranceCoverage SpecificExcess
(per occurrence)



AggregateExcess PolicyLimit: $__________________________________ LossFundPercentage: __________________________ MinimumLossFund:$___________________________ EstimatedLossFund: $__________________________ PolicyTerm:___________________________________ PolicyNumber: ________________________________ _ NameofInsurer: _______________________________ Yes Yes No No

STATUTORY PolicyLimit:________________________________
SpecificRetention: $_________________________
(per occurrence)





PolicyTerm:________________________________

PolicyNumber: _____________________________ NameofInsurer: ____________________________

13. Doyouhaveanyowned,*leasedorcharteredaircraft? Doesyourexcesspolicycoverthisadditionalexposure?

*Leasedaircraft:onethatisnotownedbytheapplicantandmadeavailablefortheuseoftheapplicantunderthetermsof arentalorleaseagreementforaperiodofnotlessthanthirty(30)consecutivedays,andoperatedbysomeoneotherthan anemployeeoftheownerorlessorofsuchaircraft. 14. Listthestatesorjurisdictionsinwhichthisapplicantoperatesasaqualifiedselfinsured.(use separate sheet if necessary) __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ a. Ifyouwereeverdeniedaself-insuredpermitornon-renewalinanystate,pleaseindicatethenameofthestateandwhy youwerenotacceptedornotrenewed.(use separate sheet if necessary) __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
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15. Givethefollowingtotalsforthemostrecentyearandprioryearsexperienceinformationforeachstatewherequalifiedasa self-insurer.(use additional sheet if necessary)Ifunavailableonastate-by-statebasis,combinedtotalsmaybegiven. State MostRecent CalendarYear Dates From To Total Average Numberof Employees TotalAnnual GrossPayroll *Indemnity Paid *Medical Paid **TotalIndemnity Unpaid (Reserves) SeeBelow **TotalMedical Unpaid (Reserves) SeeBelow

* IncludecurrentandALLprioryears ** IncludecurrentandALLprioryearsforpaymentinfuturebyself-insuredandnotbyinsurancecarrier.

16. PleasegivethefollowinginformationabouteachKansasdeath,disabilityordiseaseclaiminthepastfive(5)yearswith costsinexcessof$30,000.(use a separate page for full details) Date of Loss Numberof Employees Involved FactsofLoss,TypeofInjuryorDisease andStateBenefitsApplicable TotalEstimatedCost Indemnity Paid Medical Expense Paid Total Unpaid

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17. Doemployeesreceiveanysupplementalbenefitsinadditiontoworkerscompensationbenefits? Yes No Ifyes,describe________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

18. Arethereanyactualorpotentialoccupationaldiseaseexposuresinvolvedinapplicant'soperations? Yes No These may include dust, gases or fumes, chemicals and toxic substances, extreme changes of temperature, noises or pressure, physical vibrations, constant pressure and use, physical movement in constant repetition or radioactive rays, infectionsandorganisms,bloodbornpathogensorradiation. Ifyes,describe________________________________________________________________________________________ __________________________________________________________________________________________________

19. Pleasefurnishinformationonanysubstantialorunusualchanges(increase or decrease)inoperationsinKansasthatare plannedorthathavetakenplaceinthelastfive(5)years.(If necessary, use additional sheets and identify as Attachment(s).) __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

20. DoestheapplicanthaveanyemployeesinKansaswhoaresubjecttothe: LongshoremenandHarborWorkers'Act? JonesAct? Yes No Yes No Yes No

FederalEmployers'LiabilityAct?

Ifyes,explain__________________________________________________________________________________________

21. a. IftheemployerisratedbyStandard&PoororDun&Bradstreet,showthelatestratings,INCLUDINGthedateofthe rating:(Ultimate Parent rating if application is submitted by subsidiary). Standard&Poor_____________________________ Dun&Bradstreet ____________________________ Other______________________________________ Dated:_____________________________ Dated:_____________________________ Dated:_____________________________

b. Givefour-digitStandardIndustrialClassification(SIC)Codethatmostclearlydefinesyouroperationasreflectedinthe financialstatementssubmitted.(Ultimate Parent SIC if application is submitted by subsidiary)______________________ TheSICCodeisusedtodeterminetheappropriateDun&Bradstreetreferenceforcomparingfinancialconditiontothe industrynorm.Ifverifiableinformationfromanindustryassociationwouldbemoreappropriate,pleasesubmit. TheStandardIndustrialClassification(SIC)Codedefinesindustriesinaccordancewiththecompositionandstructureof theeconomy.Eachestablishmentisclassifiedaccordingtoitsprimaryactivity;i.e.,mining,construction,manufacturing, transportation,communications,utilities,wholesaletrade,retailtrade,services,etc.InKansas,theSICCodeisassigned byKansasDepartmentofLabor(KDOL)LaborMarketInformationServices,undercontractwiththeFederalBureau ofLaborStatistics.Eachbusinesswithoneormoreemployeesmustfilean"Employer'sQuarterlyWageReportand ContributionsReturn",FormK-CNS100,withKDOL.TheSICCodeisshownonthe"Employer'sQuarterlyWageReport andContributionsReturn,"inthelowerrightportionfollowingItem17,senteachquarterbyKDOL(generally available from your accountant).
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22. PARENT(S),AFFILIATESANDSUBSIDIARIESOFAPPLICANT: ..... List parents of applicant in hierarchical order, beginning with ULTIMATE PARENT COMPANY regardless of Kansas operation. ..... ListallaffiliatesandsubsidiariesofapplicantthatareoperatingWITHINKANSAS.

List%ofvotingstockbyeachcorporation'sdirectparent,andshowwhethercorporationisaparentorsubsidiaryoftheapplicant. Column1 TOP PARENT LegalNameofCorporation AddressofallKansasLocations (%) Parent orSub.

23.

APPLICANTDIVISIONSANDOPERATION:Year________________ ListeachKansasoperationoftheapplicant(Do not list excess insurance on this chart.) NameofOperatingUnit andLocation (IncludeStreetAddress) OperationType MainProducts, Services,Activities KansasEmployees No.Cases **Tobe Entered Self-Ins. Average AnnualGross onOSHA Number Payroll 300log Yes No

$ ________________________________________________________________________________________________________________ $ ________________________________________________________________________________________________________________ $ ________________________________________________________________________________________________________________ $ ________________________________________________________________________________________________________________ TOTALS $

**Ifno,list: (1)Fullnameofinsurancecompany________________________________________________________________, (2)policynumber__________________________________and(3)policyendingdate_______________________. Ifno,doesthisunithaveseparateemployeesandpayrolls?
K-WC 120 ­ Page 7

Yes

No

24. ALL APPLICATIONS A. PAID LOSS DATA FOR OUTSTANDING WORKERS COMPENSATION CLAIMS (Includes weekly compensation payments, travel and per diem for medical exams and or treatment, lump-sum payments, compromise settlements, hospital, appliance and medical payments, rehabilitation, and death and funeral benefits.) Amount Paid For Medical: (including payments made during the calendar year for any previous years accidents.)....................................... $___________________________ Amount Paid For Indemnity: (including payments made during the calendar year for any previous years accidents.)................................. $___________________________ Total Amount Paid in Recent Calendar Year: *............................................. $___________________________ *(This figure must equal amount shown on K-WC 92 Annual Loss Payment Reporting Form), which is: $_____________________(Reflect Form 92 figure.)













B. RESERVES FOR CLAIMS TO BE PAID IN THE FUTURE (1) RESERVE INFORMATION FOR ALL KANSAS CLAIMS INCLUDING PRIOR YEARS AND CURRENT YEAR TO DATE. Total Number of Claims: ________________________________________ Amount Reserved For Known Medical:................................................... 1a $___________________________ Amount Reserved For Known Indemnity:............................................... 1b $___________________________ (2) INCURRED BUT NOT REPORTED (IBNR) CLAIMS Total Number of Claims: ________________________________________ Amount Reserved For IBNR:..................................................................... 2a $___________________________ (3) RESERVED FOR FUTURE CLAIMS: ............................................................... 3a $___________________________ . C. TOTAL AMOUNT RESERVED:....................................................................... $___________________________ (1a + 1b + 2a + 3a)





ACCIDENT INFORMATION Duringthemostrecentcalendaryearof____________therewere__________________accidentsreported. (year) (number) Theaccidentsreportedwere_________________timelost_________________notimelost. (number) (number)

D. NAME, QUALIFICATIONS AND EXPERIENCE OF PERSON(S) EVALUATING LOSS RESERVES (Resume or attachment will be acceptable.) _________________________________________________________________________________________________ _________________________________________________________________________________________________

E. HOW ARE LOSS RESERVES FOR FUTURE LIABILITY EXPRESSED ON YOUR FINANCIAL STATEMENT _________________________________________________________________________________________________
K-WC 120 ­ Page 8

25. Provide name of responsible individual as contact for the following areas: a. Notice of Hearing: Name: ____________________________________________________________________________________ Address: (street)____________________________________________________________________________
(city)_____________________________________ (state)_________________ (zip)________________



Telephonenumber:(______)__________________________e-mail:___________________________________

b. Renewal Application: Name: ____________________________________________________________________________________ Address: (street)____________________________________________________________________________
(city)_____________________________________ (state)_________________ (zip)________________

Telephonenumber:(______)__________________________e-mail:___________________________________

c. Notice of Assessment: Name: ____________________________________________________________________________________ Address: (street)____________________________________________________________________________
(city)_____________________________________ (state)_________________ (zip)________________

Telephonenumber:(______)__________________________e-mail:___________________________________

d. Applicant's FEIN Number: ______________________________________________________________________ _

K-WC 120 ­ Page 9

SETTLEMENTANDSTIPULATIONS Employermustagreetotheconditionsandstipulationsbelowtoqualifyforself-insurerprivileges.Thisstatementmustbesigned byacorporateofficer;cityorcountyofficial;partner;orindividual;andhaveapplicant'ssealaffixedbeforeself-insurerprivileges willbeconsidered. 26. Inconsiderationoftheprivilegeofbeingaself-insurerinthestateofKansas,Iherebyagree: a. ThatIhavefiledallrequiredreportsandpaidallfeesnecessarytoremainaCorporationinGoodStandingwiththe OfficeoftheSecretaryofStateofKansas(785-296-4564). b. ThatIwilldischargemyliabilityforcompensationtoinjuredemployeesortheirdependentsinaccordancewiththe requirementsoftheWorkersCompensationActofthestateofKansas. c. ThatIwillnotsolicit,receiveorcollectanymoneyfrommyemployeesormakeanyreductionfromtheirwagesand commissionsforthepurposeofdischarginganypartofmyliabilityundertheAct. d. ThatIwillpromptlyfurnishallreportstotheKansasDivisionofWorkersCompensationwhichitmaylawfullyrequire undertheKansasWorkersCompensationAct. e. TonotifytheDivisionofWorkersCompensationinanycaseofcontemplatedliquidation,saleortransferofownership, ormaterialreductioninKansasoperation.SubjecttotheDivisionofWorkersCompensationapproval,Iwillarrangefor thepaymentofallexistingliabilityandanyliabilityarisingthereafterforwhichImaybecomelegallyliable,byguaranty bond,depositofsecurities,orasotherwiserequiredbytheDivisionofWorkersCompensation. f. Thatpriortoanychangesmadetotheexcessinsurancepolicy,IwillrequestfromtheDivisionofWorkersCompensation approvaloftheself-insuredretentionorpolicylimits,andIagreethatanyproposedchangeswillbejustifiedinnarrative formpriortotheinceptionofthepolicyordateofrenewal.

g. ThatIwillnotifytheDivisionofWorkersCompensationatleasttwenty(20)daysinadvanceofanychangeinexcess insurancecarrier.IamfamiliarwiththeinsurancelawsinKansasregardingtheplacementofexcessinsurancein theadmittedandnon-admittedexcessinsurancemarket.Also,Iamawareofthehazardsofhavingexcessworkers compensationcoveragewithanon-admittedinsurancecarrier. h. TolettheDivisionofWorkersCompensationknowaboutanychangeinthekindoramountofservicestobeperformed bytheservicecompany,ifacompanyisused. i. j. ThatIwillpromptlynotifytheDivisionofWorkersCompensationofanyunfavorableturninmyfinancialconditionwhich mightreasonablyreducemyabilitytocarrymyownriskundertheKansasWorkersCompensationAct. ThattheFormK-WC40,PostingNotice,willbedisplayedinconspicuousplaces,suchasemployeebulletinboards asrequiredbytheKansasWorkersCompensationlaw.(ThenoticesareavailableatnochargefromtheDivisionof WorkersCompensation.)

k. Immediatelyonreceivingnoticeofinjurytoordeathofanemployee,theemployershallmailordelivertotheemployee orlegalbeneficiaryaclearandconcisedescriptionof: (1) thebenefitsavailableundertheWorkersCompensationAct; (2) theprocesstobefollowedinmakingaclaimforbenefits; (3) theidentificationoftheperson,firmororganizationdirectlyresponsibleforrespondingtoandprocessingaclaim forworkerscompensationbenefits; (4) theresponsibilitiesoftheself-insuredemployer,insurancecompanyorgroup-fundedself-insuranceplan; (5) theassistanceavailablefromtheofficeofthedirectorofworkerscompensation;and (6) theaddressandatoll-freetelephonenumberthatwillfacilitateaccesstotheassistanceavailablefromthedirector's office.
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l. ThatincaseofinsolvencyIshallmakeourrecordsavailabletotheDivisionofWorkersCompensation.Ialso willdiscloseourinabilitytopaytheinjuredemployee.Iherebyagreetoallotherrequirementscontainedin K.S.A.44-532,74-712through74-719andK.A.R.51-14-4. m. That I recognize that this self-insurer permit can be cancelled at anytime for failure to comply with the requirementssetoutherein.



APPLICANT'S OFFICIAL SEAL

Employer: _______________________________________



Signature: _______________________________________ (Corporate Officer, Official of City or County Government, Partner or Individual)

PrintedName: _______________________________________ STATEOF________________________ ) ) _________________________COUNTY) fficialPosition: _______________________________________ O (The person signing the application must be the corporation President, Vice President, Secretary or Treasurer, or the corporation Assistant Secretary or Assistant Treasurer if authorized by articles of incorporation or bylaws to make this application.) (Authorized official if city or county government.)

SubscribedandSworntobeforemeat__________________________________,__________________________________, this______________________dayof_____________________________,20______.



(SEAL)

________________________________________________ (NotaryPublic) MYCOMMISSIONEXPIRES__________________________

K-WC 120 ­ Page 11