Application For Self-Insurance Page 3
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412. L
.
IST THE DESIGNATED SAFETY REPRESENTATIVE
Name
Title
Street address
City/State/Zip
Telephone
Fax
E-mail address
Attach a narrative description of the safety and loss control program components for your operations in Illinois. Do not send a manual.
13. W
?
First aid
In-plant doctor/nurse
HAT MEDICAL FACILITIES ARE AVAILABLE TO YOUR EMPLOYEES
Local clinic
Hospital
Other
(please explain)
14. I
’
F ANY OF THE APPLICANT
S EMPLOYEES HAVE EXPOSURE IN ANY DEGREE TO SUBSTANCES THAT MAY CAUSE
,
.
OCCUPATIONAL DISEASE
INDICATE THE SUBSTANCE AND APPROXIMATE PERCENTAGE OF EMPLOYEES EXPOSED
If necessary, attach a list. Include asbestos, silica dusts, any toxic, injurious, or hazardous substances, compounds, or chemicals, caustics,
fumes, noise, radiation, communicable diseases, and any other occupational disease exposures.
S
P
# A
R
F
UBSTANCE
ERCENTAGE OF EMPLOYEES EXPOSED
CCIDENT
EPORTS
ILED
L
A
IST OF
TTACHMENTS
A. A nonrefundable application fee of $500, made payable to “Illinois Self-Insurers Administrat ion Fund.”
B. Evidence of applicant’s current experience modification factor. Explain if factor is greater than one.
C. An organizational chart showing the hierarchical position of all corporate entities, including the ultimate parent. Note
the percentage of ownership and clearly indicate which entity with operations in Illinois is seeking coverage under the
certificate of self-insurance.
D. (1) Provide the ultimate parent company’s audited financial statements for the most recent year.
(2) If certified audited financial statements are not prepared, provide the financial statements prepared by an outside
accountant for the most recent year.
E. Provide the most current 10-Q or internal quarterly balance sheet and income statement of parent.
F. Evidence of the applicant’s current workers’ compensation coverage. See question 9.
G. Detailed Illinois loss runs for the last three completed years. See question 11.
H. A narrative description of the safety program components for each operation in Illinois. See question 12.
A
-
LL OF THE ABOVE
MENTIONED ITEMS MUST BE SUBMITTED
.
BEFORE A REVIEW OF THE APPLICATION MAY BE COMPLETED
S
UBMISSION OF AN INCOMPLETE APPLICATION
.
MAY DELAY THE REVIEW PROCESS
IC50s 12/04
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