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FORM 1B OKLAHOMA WORKERS' COMPENSATION COURT 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK 73105-4918 (405) 522-8600 EMPLOYERS APPLICATION FOR PERMISSION TO CARRY ITS OWN RISK WITHOUT INSURANCE To: The Oklahoma Workers' Compensation Court Date__________________________________ The undersigned, an employer subject to the provisions of the Workers' Compensation Act, hereby applies for permission to carry its own risk without insurance. To enable the Workers' Compensation Court to determine whether or not the applicant possesses sufficient financial ability to render certain the payment of any award made by the Court, said applicant hereby states the following: 1. 2. 3. 4. 5. 6. 7. 8. Employer's Name_________________________________________________________________________________ Employer's Federal Identification Number___________________________

FORM 1B

OKLAHOMA WORKERS' COMPENSATION COURT 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK 73105-4918 (405) 522-8600

EMPLOYERS APPLICATION FOR PERMISSION TO CARRY ITS OWN RISK WITHOUT INSURANCE To: The Oklahoma Workers' Compensation Court Date__________________________________

The undersigned, an employer subject to the provisions of the Workers' Compensation Act, hereby applies for permission to carry its own risk without insurance. To enable the Workers' Compensation Court to determine whether or not the applicant possesses sufficient financial ability to render certain the payment of any award made by the Court, said applicant hereby states the following: 1. 2. 3. 4. 5. 6. 7. 8. Employer's Name_________________________________________________________________________________ Employer's Federal Identification Number_____________________________________________________________ Home Office Address______________________________________________________________________________ Oklahoma principal office address____________________________________________________________________ Incorporated or organized under the laws of the State of __________________________________________________ If foreign corporation, give date licensed to do business in Oklahoma________________________________________ Nature of business________________________________________________________________________________ General Information on Company: a. b. Years engaged in continuous business_________________________, Payroll in each of the preceding three (3) years: Year:_______, $___________________; Year:_______, $___________________; Year:_______, $________________ Payroll in Oklahoma in each of the preceding three (3) years: Year:_______, $___________________; Year:_______, $___________________; Year:_______, $________________ c. Number of employees presently employed_______________ In Oklahoma______________ Estimated payroll in Oklahoma for the next twelve (12) months________________________ In Oklahoma_______________________

d. 9.

Excess Insurance Information: a. b. c. Name of carrier______________________________________________________________________________ Policy dates: Effective_____________________________ Expiration_______________________________ Limits of Liability___________________

Under this policy:

Self Insured Retention____________________

Note: A certificate of excess insurance or a valid binder issued by said carrier must be attached to this application. A copy of the policy must follow. 10. Estimated manual premium for your company_____________________________________________

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11. A. In the section below, state the loss history for the past five (5) fiscal/calendar years. Copy the requested information from your loss runs (if the hard copy of your loss runs are required you will be notified). Also include the current year's history, indicating how many months of the current year are included: Total incurred losses in Oklahoma (include for all injuries, both open & closed claims)

Year mo

$ Medical Paid

$ Indemnity Paid

$ Total Paid

$ Total Reserves Outstanding

Cases Opened

Cases Reopened

Cases Closed

Death Cases

B. Total Self Insurance Reserves Outstanding: (for all years of self insurance) Total Self Insured Open Cases: (for all years of self insurance)

$______________________

________________________________

12. A. Enclose current audited financial report, including balance sheets, income statements & notes. B. A governmental entity must provide a definite statement of the amount it has specifically appropriated for workers' compensation claims for the latest and the next fiscal year. Also, a description of how workers' compensation claims are funded must be submitted. 13. A. Is the applicant a subsidiary of another employer? ______ If yes, submit the parent company's financial statements. B. Does the applicant have subsidiary companies that it wants to include under this permit?___________________ (attach a list of the names and addresses of ALL entities to be included under this permit, including subdivisions) C. If you answered yes to either question 13A or 13B, attach a copy of a written agreement whereby the ultimate parent employer guarantees that it will be fully responsible for any liabilities that its subsidiaries may incur under the Oklahoma Workers' Compensation Act. 14. A. Name and address of the company's Third Party Administrator for the servicing of the self insurance claims. _____________________________________________________________________________ _____________________________________________________________________________ B. If an approved Third Party Administrator is not employed, please submit qualifications of benefits administrator.

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15. Attach a copy of your company's safety plan. 16. In consideration of the approval of this application, the applicant hereby expressly agrees as follows: A. The applicant's privilege to carry its own risk without insurance may be revoked at any time for good cause by the Administrator of the Workers' Compensation Court. The applicant will fully discharge by cash payment all installments of compensation for disability promptly when due. The applicant will assume liability for physician's fees, hospital services, and hospital supplies within 10 days after such liability is determined either by an agreement or an award.

B.

Include an annual application fee of $500, made payable to the Oklahoma Workers' Compensation Court. I declare under penalty of perjury that I have examined this application and all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Signed this __________ Day of _________________, ________

__________________________________________________ Print Name and Title (note: person signing should be authorized to bind the applicant to the agreements contained herein)

__________________________________________________ Signature __________________________________________________ Mailing Address __________________________________________________ Street Address, if different from Mailing Address __________________________________________________ City, State Zip Code __________________________________________________ Telephone Number __________________________________________________ E-mail Address

Send application to: Insurance Department Oklahoma Workers' Compensation Court 1915 North Stiles Ave. Oklahoma City, OK 73105-4918

Rev. 7/2007

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File Size: 51.3 kB
Pages: 3
Date: July 24, 2007
File Format: PDF
State: Oklahoma
Category: Workers Compensation
Author: jlutter
Word Count: 757 Words, 6,533 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.owcc.state.ok.us/CourtForms/Current/Form%201B.pdf