Illinois Administrative Code
Title 50 - INSURANCE
Part 575 - WORKERS' COMPENSATION POOLS
Exhibit A - Requirements for Certification of Homogeneity and Certification Format
Current through Register Vol. 48, No. 12, March 22, 2024
Certification by the Trustees
a) Each pool must certify its compliance with Section 107a.08(a) and (b) of the Illinois Insurance Code [215 ILCS 5/107a.08(a) and (b) ] to the Director by having each pool trustee file the prescribed certification form below by March 1 of each year to indicate that the pool members possess homogeneous risk characteristics. The Director may require certifications more frequently than on an annual basis if deemed necessary.
b) The Trustees shall each certify that:
c) The certification must be accompanied by a list of members as of the end of the previous year that includes for each member a description of business activities, list of NCCI class codes used to classify the member's payroll, gross annual payroll by class code, number of employees, and identification of new members added during the previous year.
d) For the initial certification, March 1, 2010, an affidavit describing the membership scope of the pool consistent with the standards prescribed in this Part must accompany the certification. Supporting documentation must be submitted that demonstrates that the membership scope possesses homogeneous risk characteristics.
STATE OF ILLINOIS
CERTIFICATION OF HOMOGENEITY
I, __________(Name of Trustee)__________ , a Trustee or Director of ________________(Name of Workers' Compensation Pool)____________ present this Certification to the Director of Insurance of the State of Illinois for the period of January 1 through December 31, _______________. I certify that:
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