Application For Certificate Of Self Insurance (Page 2 of 6) in pdf

Application For Certificate Of Self Insurance Page 2

The applicant shall submit a description of its proposed excess insurance coverage, including effective

dates, type of coverage, conditions and exclusions, with specific and aggregate retentions and policy

limits. Excess coverage must be written by a casualty insurance company or reinsurance company

authorized to transact business in Alaska, and must be rated A- or higher with a stable outlook by a

nationally recognized rating organization.

The application for self-insurance must be accompanied by a security deposit in the form of an

irrevocable letter of credit from a financial institution authorized to conduct business in Alaska under

AS 06.01.010-06.40.190, with the State of Alaska, Department of Labor and Workforce Development

listed as the beneficiary. The amount of the security deposit must be in the amount of $600,000 or 125%

of the total outstanding accrued self-insured workers’ compensation liabilities for the year immediately

preceding the application, whichever amount is greater.

The applicant shall submit with the application a detailed synopsis of its safety/loss control program.

The above material shall be mailed to the Division of Workers’ Compensation at least 90 days prior to

the desired effective date of self-insurance.

07-6129 (rev 8/2/10)

Application For Certificate Of Self Insurance Page 2