Compilation of Rules and Regulations of the State of Georgia
Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER
Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE
Subject 120-2-34 - GROUP SELF-INSURANCE FUNDS
Rule 120-2-34-.24 - Severability
If any provision of this Regulation or the application thereof to any person or circumstance, is held invalid by a court of competent jurisdiction, the remainder of the Regulation or the applicability of such provision to other persons or circumstances shall not be affected.
EXHIBIT A
OFFICE OF
COMMISSIONER OF INSURANCE
WARREN D. EVANS
COMMISSIONER OF INSURANCE
SAFETY FIRE COMMISSIONER
INDUSTRIAL LOAN COMMISSIONER
COMPTROLLER GENERAL
SEVENTH FLOOR, WEST TOWER
FLOYD BUILDING
2 MARTIN LUTHER KING, JR. DRIVE
ATLANTA, GEORGIA 30334
APPLICATION FOR CERTIFICATE OF AUTHORITY
FOR GROUP SELF-INSURANCE FUND
To the Commissioner of Insurance, State of Georgia:
Application is hereby made for a Certificate of Authority for Group
Self-Insurance Fund.
(If additional space is required to answer any question, use separate sheets of paper number each to correspond to the question being answered.)
(1) Name of Fund _________________________________________________________
(2) Address of principal office of Fund ___________________
_______________________________________________________________________
(3) Location of Fund records _____________________________________________
(4) Desired effective date of Fund _______________________________________
(5) Address of principal office of association or group ___________
_______________________________________________________________________
(6) Telephone number _____________________________________________________
(7) Name of registered agent of Fund _____________________________________
(8) Address of registered agent of Fund __________________________________
(9) List the complete membership of the Fund and their addresses:
Name Address
(10) How will the administrative obligations of the Fund be met? _______________________________________________________________________
(11) Name and address of the administrator _______________________________
(12) Is any officer or trustee of the Fund an owner, partner, officer, director, shareholder or employee of the administrator or any parent or affiliated company? ______________________________________________________
If so, explain. __________________________________________________________
(13) Name and address of designated depository ___________________________
(14) Fund balance in depository as of application date ___________________
(15) Other assets of Fund (describe) _____________________________________
(16) Estimated amount of first year normal annual premium ________________
(17) Estimated administrative costs, amount and percentage _______________
(18) Estimated first year losses based on members' loss history of last three years ______________________________________________________________
(19) Other liabilities of Fund (describe) ________________________________
(20) Has each applicant for membership been informed that it will be jointly and severally liable for all liabilities of the Fund?
_______ Yes _______ No
THE FOLLOWING MUST ACCOMPANY THE APPLICATION:
___________ A copy of the bylaws of the Fund
___________ A copy of the intrastate agreement among the members
___________ A copy of any agreement between the Fund and any contract administrator of the Fund
___________ A copy of any contract, endorsement or application form the
Fund intends to use
___________ An "Application for Membership in Group Self-Insurance
Fund" from each member of the Fund
___________ An "Application to Serve as Officer, Director or Trustee of Group Self-Insurance Fund" from any officer, director or member of the board of trustees of the Fund
___________ An "Application to Serve as Administrator of Group
Self-Insurance Fund" from any administrator of the Fund
In consideration of the approval of the application, the applicant agrees to the following:
(A) That its trustees, officers, administrator and members will comply with all provisions of O.C.G.A. Chapter 34-9, the Regulations promulgated thereunder, all lawful Orders of the Commissioner and the Rules and Order of the State Board of Workers' Compensation.
(B) That it will admit as a new member any eligible applicant who complies with the requirements of O.C.G.A. Section 34-9-152(h) and the Regulations thereunder and will notify the Commissioner of its evaluation of each new applicant for membership.
(C) That it will notify the Commissioner of the amount and method of determination of any proposed premium or other assessment to be paid by a member or members.
(D) That it will notify the Commissioner of any dividend in accordance with Regulation.
(E) That any and all books and records of the Fund will be made available for inspection and examination by the Commissioner or his representative.
(F) That the Fund will deposit acceptable securities with the Commissioner in the amount equal to twenty-five percent (25%) of the normal annual premium (ten percent (10%) if the Fund consists of a group of municipalities, counties or school boards) or post surety bond in the form prescribed by the Commissioner in the amount equal to thirty-five percent (35%) of the normal annual premium (fifteen percent (15%) if the Fund consists of a group of municipalities, counties or school boards).
(G) That it will obtain specific and aggregate excess insurance policies written by companies authorized or approved to transact insurance in this State in the amounts prescribed by Regulation or such other amounts as the Commissioner deems necessary, and that it will submit copies of these policies to the Commissioner.
(H) That it will continuously maintain these policies and will, if it desires to make any change in these policies, notify the Commissioner at least sixty (60) days before the proposed effective date of the change.
(I) That the Commissioner may, at any time, revoke, suspend or fail to renew this Certificate of Authority in accordance with O.C.G.A. Section 34-9-169.
(J) THAT THE FUND WILL NOT GUARANTEE ANY FINANCIAL OBLIGATION OF ANY of its OFFICERS, TRUSTEES OR ADMINISTRATORS. ________ (Initial)
(K) THAT NO OFFICER, TRUSTEE, ADMINISTRATOR, OR MEMBER OF ANY COMMITTEE OR EMPLOYEE OF THE FUND WHO IS CHARGED WITH THE DUTY OF INVESTING OR HANDLING THE FUND'S ASSETS WILL BORROW ANY ASSET OF THE FUND; DEPOSIT OR INVEST SUCH ASSETS EXCEPT IN THE NAME OF THE FUND; BE PECUNIARILY INTERESTED IN ANY LOAN, PLEDGE OF DEPOSIT, SECURITY, INVESTMENT, SALE, PURCHASE, EXCHANGE, REINSURANCE OR OTHER SIMILAR TRANSACTION OR PROPERTY OF THE FUND; OR TAKE OR RECEIVE FOR HIS OWN USE ANY FEE, BROKERAGE, COMMISSION, GIFT OR OTHER CONSIDERATION FOR OR ON ACCOUNT OF ANY SUCH TRANSACTION MADE BY OR ON BEHALF OF THE FUND, EXCEPT AS PROVIDED BY O.C.G.A. SECTION 34-9-180(c) OR BY REGULATION OF THE COMMISSIONER ______ (Initial)
(L) That it will notify the Commissioner within fourteen (14) days of any change in any of the information contained in this application.
_______________________________________________________________________
(PRINT NAME OF FUND)
BY:____________________
_______________________
(PRINT NAME)
_______________________
(PRINT TITLE)
_______________________
(DATE)
AFFIDAVIT
COUNTY___________
STATE ___________
I,__________________________________________________________, the undersigned being the _____________________________________________ of the
(Title)
__________________________________________________________________________
(Name of Fund)
swear (or affirm) that to the best of my knowledge and belief, the statements contained in the application, including the accompanying documents, are true and complete.
By:_____________________
Sworn before me this________________
day of______________________, 19 ___
____________________________________
NOTARY PUBLIC
My Commission Expires_______________
EXHIBIT B
OFFICE OF
COMMISSIONER OF INSURANCE
WARREN D. EVANS
COMMISSIONER OF INSURANCE
SAFETY FIRE COMMISSIONER
INDUSTRIAL LOAN COMMISSIONER
COMPTROLLER GENERAL
SEVENTH FLOOR WEST TOWER
FLOYD BUILDING
2 MARTIN LUTHER RING, JR. DRIVE
ATLANTA, GEORGIA 30334
APPLICATION FOR
RENEWAL OF CERTIFICATE OF AUTHORITY
FOR GROUP SELF-INSURANCE FUND
To the Commissioner of Insurance, State of Georgia:
_______________________________________________________________________
(NAME OF FUND)
_______________________________________________________________________
(ADDRESS)
hereby applies for the renewal of its Certificate of Authority for the year
____________. In consideration for the approval of this application, the applicant agrees to all conditions contained in the original
"Application for Certificate of Authority for Group Self-Insurance
Fund." List any changes in the information contained in the Application for Certificate of Authority, as amended by subsequent applications for renewal. Use separate sheets of paper, numbering each to correspond to the question. List changes even if the Commissioner has been notified unless such changes were listed on the previous application for renewal.
_______________________________________________________________________
(PRINT NAME OF FUND)
BY: _________________
_____________________
(PRINT NAME)
_____________________
(PRINT TITLE)
_____________________
(DATE)
AFFIDAVIT
COUNTY_____________
STATE _____________
I,_______________________________________________________, the undersigned being the__________________________________________________________ of the
(Title)
_______________________________________________________________________
(Name of Fund)
swear (or affirm) that to the best of my knowledge and belief; the statements contained in the application, including the accompanying documents, are true and complete.
By:____________________
Sworn before me this__________________
day of______________________, 19______
______________________________________
NOTARY PUBLIC
My Commission Expires_________________
EXHIBIT C
OFFICE OF
COMMISSIONER OF INSURANCE
WARREN D. EVANS
COMMISSIONER OF INSURANCE
SAFETY FIRE COMMISSIONER
INDUSTRIAL LOAN COMMISSIONER
COMPTROLLER GENERAL
SEVENTH FLOOR WEST TOWER
FLOYD BUILDING
2 MARTIN LUTHER RING, JR. DRIVE
ATLANTA, GEORGIA 30334
APPLICATION FOR MEMBERSHIP IN
GROUP SELF-INSURANCE FUND
All information pertaining to the application shall not be deemed to be a public document and shall be maintained in confidence by the Commissioner and the Fund.
To the Commissioner of Insurance of the State of Georgia and the
___________________________________________________________Fund.
Application is hereby made for membership in above Fund.
(1) Member Name ___________________________________________
(2) Address _______________________________________________
(3) Telephone Number ______________ Number of Employees____
(4) Federal Employer I.D. Number __________________________
(5) Nature of Business ____________________________________
(6) Type of Business: () Corporate () Partnership () Individual
() Other
(7) List of Partners, Owners or Corporate Officers:
NAME ADDRESS TITLE PERCENTAGE OWNERSHIP
(7a) List Chief Administrative Officer of a governmental or hospital entity:
_______________________________________________________________________
(8) If Corporation, name and address of Resident Agent____________________
_______________________________________________________________________
(9) Locations of all operations to be included in the Fund:
NAME PRINCIPAL ADDRESS TYPE OF BUSINESS
(10) If applicant is a subsidiary, name parent company:
NAME ADDRESS TYPE OF BUSINESS
IF THE APPLICANT IS UNABLE TO OBTAIN ALL THE INFORMATION REQUESTED IN QUESTION (11) IT MAY, INSTEAD, INCLUDE A CERTIFICATION SIGNED BY THE ADMINISTRATOR OR CHAIRMAN OF THE BOARD OF TRUSTEES OF THE FUND THAT the information ACTUALLY PROVIDED IS SATISFACTORY TO THE FUND.
(11) Loss history for last three completed years:
Year Ending Year Ending Year Ending
a. Number of accidents requiring medical attention only
b. Number of accidents requiring lost time of more than 3 days
Year Ending Year Ending Year Ending
c. Total paid claims $ $ $
d. Outstanding reserves $ $ $
e. Total incurred losses $ $ $
(Paid and Reserves)
f. Fatalities in the last three years: No_____ Yes_____ Number_____
If yes, explain.___________________________________________________
___________________________________________________________________
(12) Estimated premium for twelve month period
Beginning: Month________ Day______ Year _______
Classification Classification Estimated Current Estimated
Code Description Annual Rate Annual
Payroll Premium
_____________________________________________________________________
Total Payroll ____________________ Total Premium __________________
(13) Present carrier of workers' compensation insurance or indicate if applicant participated in a workers' compensation self-insurance program:
___________________________________________________________________
(14) Present workers' compensation premium_________________________
(15) Statement of Assets and Liabilities as of_____________________
(Date)
APPLICANT MAY SUBMIT A COPY OF THE MOST RECENT AUDITED FINANCIAL STATEMENT CERTIFIED BY A CERTIFIED PUBLIC ACCOUNTANT, IN LIEU OF COMPLETING QUESTIONS (15) AND (16). QUESTIONS (15) AND (16) DO NOT HAVE TO BE ANSWERED BY MUNICIPALITY, COUNTY AND SCHOOL BOARD APPLICANTS.
DOLLARS ONLY
----------------------------------------------------------------------
Current Assets: Current Liabilities:
Cash on hand ___________________ Accounts Payable __________________
Cash in bank ___________________ Notes payable given for merchandise
Notes receivable ___________________________________
(Less than 1 year old) ________ Notes payable negotiated otherwise
(not transferable) ____________ ___________________________________
Merchandise_____________________ Other current liabilities and
Other current assets: accruals:
________________________________ ___________________________________
________________________________ ___________________________________
________________________________ ___________________________________
________________________________ TOTAL CURRENT
LIABILITIES _______________________
TOTAL CURRENT ASSETS: __________ Long-Term Debt:
Fixed Assets: Notes payable _____________________
Machinery and fixtures _________ Bonded Indebtedness
(net of depreciation) _________ Mortgage Indebtedness
Real Estate Other long-term debts
(net of depreciation)__________ TOTAL LONG-TERM DEBT
Investment (describe nature TOTAL LIABILITIES
of same) _______________________
________________________________ Surplus/Owner Equity:
TOTAL FIXED ASSETS _____________ Capital Stock (Common)
Other non-current assets Paid-in excess
(describe)______________________ Retained Earnings
________________________________ Undivided Profits
________________________________ (Partnership only)
________________________________ Other _____________________________
___________________________________
TOTAL SURPLUS/OWNER EQUITY
___________________________________
TOTAL LIABILITIES, SURPLUS/
TOTAL ASSETS ___________________ OWNERS EQUITY______________________
______________________________________________________________________
______________________________________________________________________
Contingent Liability - Notes Receivable of customers discounted or sold and not included in Assets ___________________________________________
______________________________________________________________________
Other Contingent Liabilities__________________________________________
______________________________________________________________________
If a limited partnership, give date of formation and duration ________
______________________________________________________________________
STATEMENT - Is it based on actual inventory?__________________________
If so, date. ________________________
VERIFICATION - Have the books been audited by a certified public accountant? __________ If so, give date of audit. _____________
If applicant is a corporation: Authorized capital stock
(Common) $_________________________ (Preferred) $_____________________
Paid and subscribed as follows:
Cash ________________________________________ $_______________________
Patents, Trademarks _________________________ $_______________________
Goodwill ____________________________________ $_______________________
Property listed among Assets ________________ $_______________________
(16) Relate facts, covering the past three years:
Sales Expenses Payroll Profits
Inc. Payroll)
Year 19__________________________________________________________________
Year 19__________________________________________________________________
Year 19__________________________________________________________________
Amount of indebtedness past due ____________________ $ _______________
Insurance of merchandise ___________________________ $ _______________
Insurance on buildings and plant ___________________ $ _______________
(17) Safety, sanitation and welfare conditions:
Is your business or any part thereof inspected otherwise than by State
Authority? ____________ If so, by whom? _________________________________
Have you fulfilled all safety requirements of the State Board of Workers'
Compensation?__________________
Have you a committee of safety whose duty it is to recommend safety devices and to secure compliance with statutes or general orders of the
Board of Workers' Compensation as to safety and sanitation?______________
Do you maintain a hospital in connection with your works?_________________
If so, state description of its equipment and service.____________________
_______________________________________________________________________
_______________________________________________________________________
In consideration for the approval of this application, the applicant agrees as follows:
(A) That the applicant will comply with O.C.G.A. Chapter 34-9, the
Regulations promulgated thereunder, all lawful Orders of the Commissioner, the Rules and Orders of the State Board of Workers' Compensation, and the rules, regulations and bylaws of this Fund.
(B) That the applicant will be jointly and severally liable for all obligations of this Fund during the entire period of membership in the Fund.
(C) That the applicant will pay promptly any lawful premiums or assessments due as a member of the Fund.
(D) That the Commissioner will approve or disapprove this application within the time allowed by O.C.G.A. Section 34-9-155 following receipt by him of the application and all supporting information requested.
(E) That the applicant will be notified by at least first class mail as to date (12:01 a.m.) coverage begins which is understood to be the effective date of membership in the Fund.
(F) That the applicant will submit an "Application to Withdraw from
Group Self-Insurance Fund" ninety (90) days prior to voluntary withdrawal from the Fund.
(G) That the coverage under this membership shall be for Georgia operations only, including incidental coverage in other States.
(H) That the application will notify the Fund and the Commissioner within fourteen (14) days of any change in any of the information contained in questions (1) through (10) of this application.
PLEASE SIGN BELOW - INDICATING THAT YOU HAVE READ AND UNDERSTAND THE ABOVE A. - H.
______________________________
(PRINT NAME OF APPLICANT)
BY: __________________________
______________________________
(PRINT NAME)
______________________________
(PRINT TITLE)
______________________________
(DATE)
AFFIDAVIT
COUNTY________________________
STATE ________________________
I,____________________________________________________, the undersigned being the__________________________________________________of the
(Title)
_______________________________________________________________________
(Name of Applicant)
swear (or affirm) that to the best of my knowledge and belief, the statements contained in the application, including the accompanying documents, are true and complete.
BY:______________________
Sworn to and subscribed before me this_______________________________
day of______________________, 19___.
___________________________________
NOTARY PUBLIC
My Commission Expires______________
EXHIBIT D
OFFICE OF
COMMISSIONER OF INSURANCE
WARREN D. EVANS
COMMISSIONER OF INSURANCE
SAFETY FIRE COMMISSIONER
INDUSTRIAL LOAN COMMISSIONER
COMPTROLLER GENERAL
SEVENTH FLOOR WEST TOWER
FLOYD BUILDING
2 MARTIN LUTHER RING, JR. DRIVE
ATLANTA, GEORGIA 30334
APPLICATION FOR TERMINATION OF MEMBERSHIP
IN GROUP SELF-INSURANCE FUND
_______________________________________, a member in good standing of the _________________________________________ Fund, hereby applies to terminate its membership in the Fund effective ______________________, which date will comply with O.C.G.A. Section 34-9-156 requiring the member to give ninety (90) days advance written notice to the Fund and to the Commissioner. The applicant understands and agrees that it will remain jointly and severally liable for all obligations of the Fund as of the date of termination. The applicant will continue to comply with its obligations as an employer under O.C.G.A. Chapter 34-9 as follows: "Secure and maintain full insurance against his liability for payment of workmen's compensation to his employees or provide the State Board of Worker's Compensation with satisfactory proof of his financial ability to pay the compensation directly in the amount and manner and when due as provided in O.C.G.A. Chapter 34-9."
__________________________________
(PRINT NAME OF MEMBER)
BY: ______________________________
__________________________________
(PRINT NAME)
__________________________________
(PRINT TITLE)
__________________________________
(DATE)
AFFIDAVIT
COUNTY_____________
STATE _____________
I,______________________________________________________, the undersigned being the _______________________________________________________ of the
(Title)
______________________________________________________________________
(Name of Applicant)
swear (or affirm) that to the best of my knowledge and belief; the statements contained in the application, including the accompanying documents, are true and complete.
By:_________________________
Sworn to and subscribed before me this________________________________
day of_____________________, 19_____.
____________________________________
NOTARY PUBLIC
My Commission Expires_______________
EXHIBIT E
OFFICE OF
COMMISSIONER OF INSURANCE
WARREN D. EVANS
COMMISSIONER OF INSURANCE
SAFETY FIRE COMMISSIONER
INDUSTRIAL LOAN COMMISSIONER
COMPTROLLER GENERAL
SEVENTH FLOOR WEST TOWER
FLOYD BUILDING
2 MARTIN LUTHER RING, JR. DRIVE
ATLANTA, GEORGIA 30334
APPLICATION TO SERVE AS
OFFICER, DIRECTOR OR TRUSTEE OF
GROUP SELF-INSURANCE FUND
To the Commissioner of Insurance, State of Georgia, and the _____________________________________________________________ Fund:
Application is hereby made to serve as ______________________ of the Fund.
(If additional space is required to answer any question, use separate sheets of paper, numbering each to correspond to the question being answered.)
(1) Name__________________________________________________________________
(2) Address_______________________________________________________________
(3) Telephone Number _____________________________________________________
(4) Name of Fund _________________________________________________________
(5) Address of Fund ______________________________________________________
(6) Position applied for__________________________________________________
(7) Term of Office _______________________________________________________
(8) Duties________________________________________________________________
(9) Date of Birth ________________________________________________________
(10) Social Security Number ______________________________________________
(11) Have you been convicted of any crime other than minor traffic violations within the last ten years? _____________________If so, explain.
______________________________________________________________________
_______________________________________________________________________
(12) Are you an owner, officer, director, shareholder or employee of any administrator or any parent of affiliated company? ___________ If so, explain.____________________________________________________________
_______________________________________________________________________
(13) Educational Background. List all institutions of higher learning,
dates attended, areas of study and degrees received. Include any specialized training, courses or seminars.
(14) Experience. List all relevant employment experience. Include at least three professional references. Include any specialized licenses in any state, memberships in professional, technical or honorary societies, publications, honors or awards. If any license has been refused, suspended, cancelled or revoked, explain.
(15) Have you ever been an officer, director, trustee, investment committee member, key employee or major stockholder of any company which became insolvent, received a cease and desist order, was placed in receivership or conservatorship, was charged with any securities regulation or any insurance violation regulation? ___________________ If so, explain. _______________________________________________________________________
_______________________________________________________________________
(16) Have you ever been declared bankrupt? ________________________ If so, explain. _________________________________________________________________
Enclose any proposed contract with the Fund providing for compensation to the applicant, organization, company or firm in which the applicant is interested.
In consideration for the application, the applicant agrees as follows:
(A) That the applicant will comply with all provisions of O.C.G.A. Chapter 34-9, the Regulations promulgated thereunder, all lawful Orders of the Commissioner, the Rules and Orders of the State Board of Workers' Compensation, the bylaws of the Fund and the terms of any contract with the Fund approved by the Commissioner.
(B) THAT THE APPLICANT WILL BE IN A FIDUCIARY RELATIONSHIP WITH RESPECT TO ANY MONIES OF THE FUND RECEIVED, COLLECTED, DISBURSED, OR INVESTED._______ (Initial)
(C) THAT NO FINANCIAL OBLIGATION OF THE APPLICANT WILL BE GUARANTEED BY THE FUND. ______(Initial)
(D) THAT THE APPLICANT AND ANY COMPANY OR FIRM IN WHICH THE APPLICANT IS INTERESTED WILL NOT DEPOSIT OR INVEST THE FUND'S ASSETS EXCEPT IN THE NAME OF THE FUND, BORROW THE ASSETS OF THE FUND; BE PECUNIARILY INTERESTED IN ANY LOAN, PLEDGE OF DEPOSIT, SECURITY, INVESTMENT, SALE, PURCHASE, EXCHANGE, REINSURANCE OR OTHER SIMILAR TRANSACTION OR PROPERTY OF THE FUND; TAKE OR RECEIVE FOR HIS OWN USE ANY FEE, BROKERAGE, COMMISSION, GIFT, OR OTHER CONSIDERATION FOR OR ON ACCOUNT OF ANY SUCH TRANSACTION MADE BY OR ON BEHALF OF THE FUND; EXCEPT IN ACCORDANCE WITH O.C.G.A. SECTION 34-9-180 OR FOR REASONABLE COMPENSATION FOR SERVICES PERFORMED OR SALES OR PURCHASES MADE TO OR FOR THE FUND IN ACCORDANCE WITH THE TERMS OF A CONTRACT APPROVED BY THE COMMISSIONER. ________(Initial)
(E) That any contract providing for compensation from the Fund to the applicant or any company or firm in which the applicant is interested must be approved and may be modified by the Commissioner. In the event of modification by the Commissioner, the applicant reserves the right to withdraw this application.
(F) That the applicant will notify the Fund and the Commissioner within fourteen (14) days of any change in any of the information contained in this application.
______________________
(NAME)
AFFIDAVIT
COUNTY___________
STATE _____________
I,____________________________________________________, the undersigned, being the __________________________________________________of the
(Title)
_______________________________________________________________________
(Name of Applicant)
swear (or affirm) that to the best of my knowledge and belief the statements contained in the application, including the accompanying documents, are true and complete.
BY:_______________________
Sworn to and subscribed before me this________________________________
day of______________________, 19____.
____________________________________
NOTARY PUBLIC
My Commission Expires_______________
EXHIBIT F
OFFICE OF
COMMISSIONER OF INSURANCE
WARREN D. EVANS
COMMISSIONER OF INSURANCE
SAFETY FIRE COMMISSIONER
INDUSTRIAL LOAN COMMISSIONER
COMPTROLLER GENERAL
SEVENTH FLOOR WEST TOWER
FLOYD BUILDING
2 MARTIN LUTHER RING, JR. DRIVE
ATLANTA, GEORGIA 30334
APPLICATION TO SERVE AS
ADMINISTRATOR OF
GROUP SELF-INSURANCE FUND
To the Commissioner of Insurance, State of Georgia, and the __________
__________________________________________________________________ Fund:
Application is hereby made to administer the Fund.
(If additional space is required to answer any question, use separate sheets of paper, number each to correspond to the question being answered.)
(1) Name__________________________________________________________________
(2) Address_______________________________________________________________
(3) Telephone Number______________________________________________________
(4) Name of Fund _________________________________________________________
(5) Address of Fund ______________________________________________________
(6) Status: () Corporation () Partnership () Individual
(7) List Names and Addresses of Owners and Partners ______________________
_______________________________________________________________________
(8) If Administrator is a company, list name and address of Resident Agent
_______________________________________________________________________
(9) List the names, addresses, and titles of the officers and directors of the administrator:
Name Address Title
(10) Have any of the above-named people been convicted of any crime other than minor traffic violations within the last ten years? _____________ If so, explain. _____________________________________________________________
(11) Is any officer or trustee of the Fund an owner, partner, officer,
director, stockholder or employee of the administrator or any parent or affiliate company? ______________ If so, explain. _______________________________________________________________________
_______________________________________________________________________
(12) Are you affiliated with or a subsidiary of a company licensed to transact insurance in this State? __________ If so, list names and address.
______________________________________________________________________________________________________________________________________________
(13) List all administrative services you intend to perform.
(14) List those individuals primarily responsible for administering the
Fund and give their experience and educational background including any license in this or any other state within the last ten years. If any license has ever been refused, suspended, cancelled or revoked, explain. Include all institutions of higher learning, dates attended and degrees received, any specialized training courses or seminars, membership in professional, technical or honorary societies, publications, honors or awards. List at least three different professional references for each individual.
(15) Detail the organizational structure and staff, available facilities, equipment and support personnel, how the various administrative services will be performed, and indicate the location in the structure of each individual in question (14).
Enclose a copy of your most recent audited statement of your financial condition (or the most recent annual statement if an insurance company) and of any agreement or contract between you and the Fund.
In consideration for this application, the applicant agrees as follows:
(A) That the applicant will comply with O.C.G.A. Chapter 34-9, the
Regulations promulgated thereunder, all lawful Orders of the Commissioner, the Rules and Orders of the State Board of Workers' Compensation, the rules, regulations and bylaws of the Fund and the terms of any contract with the Fund approved by the Commissioner.
(B) THAT THE APPLICANT AND ITS EMPLOYEES WILL BE IN A FIDUCIARY RELATIONSHIP WITH RESPECT TO ANY MONIES OF THE FUND RECEIVED, COLLECTED, DISBURSED OR INVESTED. _______ (Initial)
(C) THAT THE FUND WILL NOT GUARANTEE ANY FINANCIAL OBLIGATION OF the applicant OR ANY OF ITS EMPLOYEES._______(Initial)
(D) THAT THE APPLICANT, ITS EMPLOYEES, AND ANY COMPANY OR FIRM IN which the APPLICANT IS INTERESTED WILL NOT DEPOSIT OR INVEST THE FUND'S ASSETS EXCEPT IN THE NAME OF THE FUND; BORROW THE ASSETS OF THE FUND; BE PECUNIARILY INTERESTED IN ANY LOAN, PLEDGE OF DEPOSIT, SECURITY, INVESTMENT, SALE, PURCHASE, EXCHANGE, REINSURANCE OR OTHER SIMILAR TRANSACTION OR PROPERTY OF THE FUND; TAKE OR RECEIVE FOR HIS OR THEIR OWN USE ANY FEE, BROKERAGE, COMMISSION, GIFT, OR OTHER CONSIDERATION OF THE FUND; EXCEPT IN ACCORDANCE WITH O.C.G.A. SECTION 34-9-180, OR FOR REASONABLE COMPENSATION FOR SERVICES PERFORMED OR SALES OR PURCHASES MADE TO OR FOR THE FUND IN ACCORDANCE WITH THE TERMS OF A CONTRACT APPROVED BY THE COMMISSIONER. ________ (Initial)
(E) That any contract providing for compensation from the Fund to the applicant or any company or firm in which the applicant is interested must be approved and may be modified by the Commissioner. In the event of modification by the Commissioner, the applicant reserves the right to withdraw this application.
(F) That the applicant will obtain and maintain a fidelity bond in the amount of $100,000 written by a company authorized to transact insurance in this State and will submit a copy of the bond to the Commissioner.
(G) That the applicant will obtain errors and omissions coverage or other appropriate liability insurance written by a company authorized to transact insurance in this State, in the amount of at least $100,000, and that it will submit a copy of this policy to the Commissioner.
(H) That the applicant will continuously maintain this policy throughout the term as administrator and will, if it desires to make any change in this policy, notify the Commissioner at least sixty (60) days before the proposed effective date of the change.
(I) That the applicant notify the Fund and the Commissioner within fourteen (14) days of any change in any of the information contained in this application.
____________________________
(PRINT NAME OF ADMINISTRATOR)
BY: ________________________
____________________________
(PRINT NAME)
____________________________
(PRINT TITLE)
____________________________
(DATE)
EXHIBIT G
OFFICE OF
COMMISSIONER OF INSURANCE
WARREN D. EVANS
COMMISSIONER OF INSURANCE
SAFETY FIRE COMMISSIONER
INDUSTRIAL LOAN COMMISSIONER
COMPTROLLER GENERAL
SEVENTH FLOOR WEST TOWER
FLOYD BUILDING
2 MARTIN LUTHER RING, JR. DRIVE
ATLANTA, GEORGIA 30334
GROUP SELF-INSURANCE BOND
KNOW ALL MEN BY THESE PRESENTS, that ____________________________________
______________________________________________________________________,
a group self-insurance fund as defined in the laws of the State of ______, as Principal, _________________, a corporation duly incorporated under the laws of the State of ___________, as Surety, are held and firmly bound unto the State of Georgia in the full and just sum of ____________________ dollars, current money of the United States, to be paid to the State of Georgia, to the payment we hereby bind ourselves and each of us, our and each of our successors and assigns, jointly and severally, firmly by these presents, sealed with our seals and dated this _______ day of _________ A.D., 19____.
WHEREAS, the above bounden __________________________ did on the _______ day of ____________________, A.D., 19 _______, file with the Commissioner of Insurance of Georgia its application for a certificate of authority for group self-insurance fund under O.C.G.A. Section 34-9-152.
AND WHEREAS, the Commissioner on the _______ day of _______, A.D.,
19______, granted the application for the certificate of authority upon condition that _____________________ group self-insurance fund enter into bond in the penalty of _________ dollars conditioned among other things that the fund shall abide by and perform the requirements of the aforesaid Act with reference to paying or furnishing compensation, medical or surgical services, etc., and the rules and regulations that are now or may hereafter be adopted by the Commissioner of Insurance and the State Board of Workers' Compensation.
NOW, THEREFORE, the condition of this obligation is such that if the above bounden __________________________ shall well and truly, from time to time, and at all times hereafter, abide by and perform all the requirements of the aforesaid Act and of any amendments thereto, as well as the rules and regulations that now are or hereafter may be adopted by the State board of Workers' Compensation of Georgia, respecting the payment of the Compensation to any covered injured employees or the dependents of killed employees, and the furnishing at its own cost the expenses of medical, surgical and other services, and funeral expenses as provide in the Act, then this obligation shall be void, otherwise to remain in full force and virtue in law.
This Bond may be cancelled at any time by the Surety upon giving sixty (60) days written notice to the Commissioner of Insurance of Georgia, in which event liability of the Surety shall, at the expiration of the said sixty (60) days, cease and determine, except as to such liability of the Principal on account of injury or death to any covered employees, as may have accrued prior to the expiration of the sixty (60) days, it being understood that the Surety shall be liable, within the penal sum mentioned herein, for the default of the Principal in fully discharging any liability on its part accruing during the life of this obligation.
IN WITNESS WHEREOF, the said Principal has caused these presents to be executed by the signature of the Chairman of its Board of Trustees and the said Surety has caused these presents to be executed by the signature of its _____________________________________ and its corporate seal affixed thereto (Agent or Attorney-in-Fact) with attestation where required.
This ____________ day of ____________________, 19 ______.
________________________________________
(Principal) (Name of Fund)
BY:_____________________________________
Title: Chairman, Board of Trustees______
________________________________________
(Surety)(Name of Company)
BY:_____________________________________
Title: _________________________________
Attest: ________________________________
(If required by Power-of Attorney)
Title: _________________________________
________________________________________
(SURETY'S SEAL) (Licensed Registered Agent)
Attest as to Seal:
BY: _____________________________
Title: __________________________
EXHIBIT H
OFFICE OF
COMMISSIONER OF INSURANCE
WARREN D. EVANS
COMMISSIONER OF INSURANCE
SAFETY FIRE COMMISSIONER
INDUSTRIAL LOAN COMMISSIONER
COMPTROLLER GENERAL
SEVENTH FLOOR WEST TOWER
FLOYD BUILDING
2 MARTIN LUTHER RING, JR. DRIVE
ATLANTA, GEORGIA 30334
ADMINISTRATOR'S FIDELITY BOND FOR
GROUP SELF-INSURANCE
STATE OF GEORGIA
COUNTY OF ___________________
KNOW ALL MEN BY THESE PRESENTS:
That ____________________________________________________________, whose place of business in the City of ________________________, as Principal, and __________________________________, as Surety, a corporation duly authorized to write surety bonds in this State, are held and firmly bound unto Warren D. Evans, Commissioner of Insurance, State of Georgia, and his successors in office in the penal sum of ONE HUNDRED THOUSAND DOLLARS ($100,000.00) lawful money of the United States of America, for the payment of which well and truly to be made, we bind ourselves, and each of our heirs, executors, administrators, successors and assigns jointly, severally and firmly by these presents:
WHEREAS, the above bounden Principal pursuant to the provisions of O.C.G.A. Chapter 34-9, entitled "Group Self-Insurance Funds," is about to apply or has applied to the Commissioner of Insurance of the State of Georgia to act as administrator of the _______________________________________________
_______________________________________________ Fund.
NOW, THEREFORE, the conditions of the above obligation are such that if the said above bounden Principal shall fully and faithfully comply with the requirements of the said Chapter, and the laws of this State, and shall properly account for all monies collected in connection therewith, then this obligation is to be void, otherwise to remain in full force and effect.
This bond shall remain in full force and effect until the surety is released from liability by the Commissioner or until the bond is cancelled by the surety. The bond may not be cancelled or terminated unless sixty (60) days prior written notice is filed with the Commissioner.
IN WITNESS WHERE OF, the said Principal has caused these presents to be executed by lawful signature under seal and the said surety has caused these presents to be executed by the signature of its_______________________________ and its corporate seal to be affixed
(Agent or Attorney-in-Fact)
there to, with attestation where required.
This ________ day of _____________________________, 19____.
_________________________________________
(Principal)(Name of person, corporation, partnership, etc.)
By: _____________________________________
(ADMINISTRATOR'S SEAL) Title: __________________________________
Attest: ____________________ Attest: _________________________________
Title: _____________________ Title: __________________________________
(Secretary of Assistant Secretary)
By: _____________________________________
(SURETY'S SEAL) Title: __________________________________
Attest: ____________________ Attest: _________________________________
(If required by Power-of-Attorney)
Title: __________________________________
_________________________________________
(Licensed Registered Agent)
O.C.G.A. Sec. 33-2-9.
