SECTION 810:25-11-2. Additional application requirements

  The Application for a new Group Self-Insurance Association Permit provided for in 810:25-11-1 shall be submitted in a manner prescribed by the Commission at least sixty (60) days before the desired effective date and include all of the following:

(1)   A One Thousand Dollar ($1,000.00) nonrefundable application fee, made payable to the Commission;

(2)   A sample of the members' indemnity agreement and power of attorney, as required by 810:25-11-15, binding the association and each member thereof, jointly and severally, to comply with the provisions of the AWCA;

(3)   An executed copy of the application of each employer for membership in the association. The application must be on a form approved by the Commission and include the following:

(A)   An indemnity agreement and power of attorney executed by the employer;

(B)   A joint and several liability agreement executed by the employer;

(C)   The employer's current audited financial statement for the two previous fiscal years, including a balance sheet, statement of income, statement of cash flows, and notes;

(D)   If audited financial statements are not available, the employer should provide the employer's financial statement for the two previous years signed by two (2) company executives, including a balance sheet, statement of income, statement of cash flows and notes; and

(E)   A balance sheet and income statement for the current fiscal year.

(4)   A pro forma financial statement of the association, showing the estimated revenues and expenses for the first fiscal year of the association. Project estimated expenses in dollar amount and percentage of the expected estimated premium;

(5)   A statement of the collective net worth of the members of the association;

(6)   The estimated standard and discounted premium each association member will pay during the first fiscal year of the association;

(7)   Underwriting guidelines that will be used by the association, including a listing of the type, amount and eligibility requirements of discounts available for the association members;

(8)   Specific and aggregate excess insurance binders for the first fiscal year;

(9)   A copy of the association's bylaws and any other governing instruments of the proposed association;

(10)   A designation of the initial members' supervisory board and of the administrator of the association, including properly executed biographical affidavits for each;

(11)   A copy of the contract(s) between the association and all TPAs, including a cover page for each contract which indicates the nature of services provided by the TPA (i.e., claims management, safety, marketing, underwriting or accounting services);

(12)   A copy of all fidelity bonds and errors and omissions policies secured by the association, its administrator, and organizations providing services to the association, with the exception of any TPAs;

(13)   Copies of all marketing materials to be utilized by the association; and

(14)   A list of workers' compensation rates to be charged to its members, broken down by classification code. The rates should be calculated in accordance with 810:25-11-8.

[Source: Added at 31 Ok Reg 497, eff 2-4-14 (emergency); Added at 32 Ok Reg 1493, eff 8-27-15; Amended at 33 Ok Reg 1993, eff 9-12-16; Amended at 35 Ok Reg 2312, eff 9-14-18]