| The following forms are available upon request from the Commission and contain requests for the information listed in each subsection.
1. Initial Application for Authority to Self-Insure:
a. Name of the pool;
b. Address and telephone number of the pool's principal office;
c. Effective date of formation of the pool;
d. Name and address of each member of the pool;
e. Two digit standard industrial classification code for each member of the pool;
f. Name and address of the industry or trade association, or professional organization to which members of the pool belong;
g. Effective date of formation of the industry or trade association, or professional organization to which members of the pool belong;
h. Type of business in which members are engaged and length of time in business for each member;
i. Explanation of how businesses of members are the same or similar;
j. Amount of workers' compensation insurance premiums paid by each member in the preceding year;
k. Names and addresses of the board of trustees;
l. Name, address, and telephone number of the administrator appointed by the board of trustees;
m. Name, address, and telephone number of the service company, if applicable;
n. Names, titles, addresses, and telephone numbers of the persons in charge of the loss control and underwriting programs;
o. Premium tax plan selection;
p. Authorized signature and title of person signing initial application;
q. Statement that all information and assertions contained in the application and the documents accompanying the application are factually correct and true; and
r. Date of execution of the initial application.
2. Renewal Application:
a. Name of the pool;
b. Address and telephone number of the pool's principal office;
c. Name and address of each member of the pool and the effective date of membership;
d. Renewal date of the pool;
e. Effective date of initial authority to self-insure;
f. Total number of member employees covered by the pool;
g. Total payroll of the pool for the last fiscal year;
h. Name, address, and telephone number of the administrator;
i. Name, address, and telephone number of the service company, if applicable;
j. Name, address, and telephone number of the excess insurance carrier;
k. Name and address of the companies providing guaranty bond and fidelity policy;
l. Name and address of individuals serving on the board of trustees;
m. Names, titles, addresses, and telephone numbers of persons in charge of loss control and underwriting programs;
n. Authorized signature and title of person signing renewal application;
o. Statement that all information and assertions contained in the renewal application and the documents accompanying the renewal application are factually correct and true; and
p. Date of execution of the renewal application.
3. Self-Insurance Guaranty Bond Form:
a. Pool identification;
b. Names of fidelity and surety insurance companies;
c. Description of the bond, including the amount and conditions of the bond obligations and liability of surety;
d. Statement regarding the responsibility for fees and costs associated with the collection of the bond and the responsibility for payment of any award or judgment against the surety;
e. Authorized signatures and titles by pool, surety, and agent; and
f. Date of execution of the guaranty bond form.
4. Option Election Form:
a. Calculation and selection of type of guaranty bond and securities;
b. Description of incurred liability and anticipated future liability (compensation and medical) on all open cases for the preceding 4 years and the current year;
c. Authorized signature and title of person signing option election form;
d. Statement that all information and assertions contained in the form are factually correct and true; and
e. Date of execution of the option election form.
5. Self-Insured Payroll Report:
a. Description of the cumulative payroll for all members of the pool (classification codes, methods and types of pay);
b. Amount paid in the preceding calendar year;
c. Authorized signature and title of person signing self-insured payroll report;
d. Statement that all information and assertions contained in the report are factually correct and true; and
e. Date of execution of self-insured payroll report.
6. Self-Insured Medical Report:
a. Description of costs relating to industrial injuries;
b. Reinsurance premiums paid;
c. Total expenditures for workers' compensation and occupational disease claims;
d. Authorized signature and title of person signing self-insured medical report;
e. Statement that all information and assertions contained in the report are factually correct and true; and
f. Date of execution of the self-insured medical report.
7. Self-Insured Injury Report:
a. Description of specific information for the current year and 3 preceding years for each injury requiring payment in excess of $5000 which includes accumulated amount paid and reserved for each claim in excess of $5,000;
b. Description of all injuries for the current year and 3 preceding years if individual injury required payment of less than $5,000;
c. Authorized signature, title, and telephone number of person signing self-insured injury report;
d. Statement that all information and assertions contained in the report are factually correct and true; and
e. Date of execution of the self-insured injury report.
8. Quarterly Tax Payment Form:
a. Name and address of the pool;
b. Description and calculation of the quarterly tax and designation of the applicable quarter;
c. Amount of annual tax paid in the previous calendar year; amount of the quarterly tax paid adjusted for change in the tax rate;
d. Description and calculation of any penalty due;
e. Authorized signature, title and telephone number of person signing the quarterly tax payment form;
f. Statement that all information and assertions contained in the form are factually correct and true; and
g. Date of execution of the quarterly tax payment form.
9. Application to Add a Member to Self-Insured Pool:
a. Name of the pool and name of the member to be added to the pool, including if applicable, addresses, corporation, subsidiary, partnership, and trust information;
b. Nature and years in business of the member to be added;
c. History of business in Arizona and elsewhere for the member to be added;
d. Payroll data for each member to be added;
e. Work force data for each member to be added;
f. Financial data for each member to be added;
g. Insurance data for each member to be added;
h. Two digit standard industrial classification code for each member of the pool;
i. Workers' compensation claims, loss and performance history for the member to be added;
j. Authorization by board resolution approving addition of each new member;
k. Authorized signature and title of person signing application;
l. Statement that all information and assertions contained in the application are factually correct and true; and
m. Date of execution of the application.
10. Notice Confirming Addition of Member to Pool:
a. Name of the pool;
b. Name and address of the new member;
c. Effective date of membership;
d. Rate and code classification to be applied to new member;
e. Standard industrial classification code for new member;
f. Authorized signature and title of person signing notice;
g. Statement that all information and assertions contained in the notice are factually correct and true; and
h. Date of execution of the notice.
11. Notice of Termination of Membership:
a. Name and address of pool;
b. Effective date of termination;
c. Name and address of the member to be terminated, identified as follows:
i. All names and addresses of every location used by the member;
ii. If the member is a partnership, the names and addresses of all the partners;
iii. If the member is a corporation doing business under a number of divisions, the notice shall state the names of all the divisions of the corporation; and
iv. If a member changes names, both the new and former names.
d. Authorized signature, title and telephone number of person signing notice;
e. Statement that all information and assertions contained in the notice are factually correct and true; and
f. Date of execution of the notice.
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