Supplemental Application Subsidiary Coverage For Workers Compensation Self Insurers printable pdf download

Supplemental Application Subsidiary Coverage For Workers Compensation Self Insurers

SUPPLEMENTAL APPLICATION

SUBSIDIARY COVERAGE FOR WORKERS’ COMPENSATION SELF-INSURERS

______________________________________________________________, a corporation duly

organized under the laws of the State of ____________________________________________,

which has previously been approved by the Industrial Commission of the State of Idaho to act as

a workers’ compensation self-insured employer, hereby applies for extension of such authority to

self-insure to the following wholly-owned subsidiary corporation(s) of such parent corporation:

________________________________________________________________________

In support of such application, the applicant hereby certifies as follows:

That the three-year average payroll of its wholly-owned subsidiary corporation(s)

is as follows:

19____:

$_______________

20____:

$_______________

Average: $_______________

20____:

$_______________

That it has made an additional deposit with the Idaho State Treasurer in the

amount of $_______________, in the form of _______________________________________

equaling 5% of the average annual payroll for the wholly-owned subsidiary corporation(s)

(subject to the maximum limitations set out in the regulations relating to self-insured employers),

together with all outstanding and unpaid awards of compensation against such wholly-owned

subsidiary corporation(s) under the Idaho Workers’ Compensation Law.

Supplemental Application Subsidiary Coverage For Workers Compensation Self Insurers