Application For Certificate Of Self Insurance printable pdf download

INSTRUCTIONS FOR QUALIFYING AS A SELF-INSURED EMPLOYER IN ALASKA

REQUIREMENTS-

8 AAC 46.010 provides that a person may self-insure their workers compensation liability under the

Alaska Workers’ Compensation Act (Act) if it has

(1) the financial ability to meet the self-insured’s financial obligations in Alaska;

(2) available claims facilities through its own staffed adjusting facilities located within this state or

through independent, licensed, resident adjusters with power to effect settlement within this state. For

purposes of this paragraph, insurance companies with a certificate of authority from the division of

insurance, Department of Commerce and Economic Development, and with staff adjusters in this state,

are considered independent, licensed, resident adjusters;

(3) been in business within Alaska for at least five years immediately preceding the filing of the

application for self-insurance;

(4) a safety/loss control program;

(5) in combination with its parent company or subsidiary companies, a minimum of 100 employees

either in Alaska or in another state or states; and

(6) a tangible net worth of at least $10,000,000.

The board will, in its discretion, waive the requirement in (3) of this section

(1) if the employer has self-insured its workers' compensation obligations in another jurisdiction for a

period of at least five years immediately preceding the filing of the application; or

(2) if the employer is a wholly-owned subsidiary and its parent company has been in business for at

least five years immediately preceding filing and guarantees the subsidiary's obligations under the Act.

FILING REQUIREMENTS-

An application for a Certificate of Self Insurance must be made on form 07-6129.

An applicant that has multiple subsidiaries must list each subsidiary to be covered under the certificate

of self-insurance, including the legal name, mailing address, federal identification number, and

ownership information for each subsidiary.

An applicant that is a wholly owned subsidiary of another company, must submit a parent company

guarantee of the applicant’s obligations under the Act.

If the applicant is a joint venture, the partner with the majority interest in the venture must be self-

insured in Alaska, or qualified to be self-insured in this state. The joint venture application must include

financial information for each partner in the venture, and the application must be accompanied by a copy

of the joint venture’s operating agreement.

The application must be accompanied by the applicant's audited financial statements for the three fiscal

or calendar years immediately preceding the filing of the application. The applicant may submit

consolidated financial statements of its parent company if the applicant does not have its own audited

financial statements and the employer is a majority or wholly-owned subsidiary. A public entity must

submit audited comprehensive annual financial reports, including detailed schedules.

The applicant shall provide a summary of the employer’s or the employer’s parent company payroll and

loss runs for the three fiscal years or calendar years preceding the filing of the application. The

summary must be categorized by year, and include the number of employees, amount of payroll, number

of medical-only claims, number of indemnity claims, number of fatalities, the dollar amount of total

incurred losses, the dollar amount of paid losses, the dollar amount of reserves for incurred but unpaid

losses, the dollar amount of losses within the retention limit, the dollar amount of losses subject to

reinsurance or excess recovery, and the dollar amount of losses subject to subrogation recovery.

07-6129 (rev 8/2/10)

Application For Certificate Of Self Insurance

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