(1) Every employer
desiring to be licensed as a self insurer shall make application therefore on
forms provided by the Department. The application shall be in such form as the
Department may provide and shall contain such information as the Department may
require. Employers shall, upon request of the Department, furnish such
additional information as the Department may require. Except as provided by any
law to the contrary, any information shall be confidential and used only for
the purpose of determining the ability of the employer to be a self insurer. A
new application shall be filed with the Department at least 90 days prior to
the proposed effective date of said license; a renewal application shall be
filed at least 60 days prior to the renewal date.
(2) In addition to 452 CMR 5.02(1), each
applicant shall furnish to the Department:
(a)
a sworn, itemized statement of the assets and liabilities of the applicant,
separately showing assets owned in the Commonwealth;
(b) a payroll report for the preceding fiscal
year and expected payroll for the next fiscal year along with the total number
of persons employed by the applicant in the Commonwealth;
(c) a detailed description of the nature and
kind of business carried on by the applicant in the Commonwealth including the
legal status of the applicant and its status as a subsidiary or other affiliate
of any other business entity;
(d)
the location of the applicant's home office, principal office and all offices
and locations in the Commonwealth, including mailing addresses and contact
persons;
(e) a list of the names
and addresses of owners, partners, officers and directors of the applicant
including the name(s) of in-state residents for purposes of service of
process;
(f) a report showing the
name of the applicant's reinsurers, the effective dates of the policies,
whether the reinsurance is specific or aggregate and the minimum and maximum
amount of such coverage;
(g) the
amount, if any, of outstanding workers' compensation liabilities, both incurred
and paid, of previous policy years. A new application must list the previous
three years of premium, losses and experience modification factors. A renewal
application will show the complete loss experience for the prior four years if
self insured for that period;
(h)
evidence that the applicant has complied with M.G.L. c. 152, § 25A(2) and
452 CMR
5.03;
(i) evidence that the corporate policy of the
applicant is to comply with OSHA safety requirements;
(j) a report showing arrangements made by the
applicant for the handling of work related injuries in conformity with M.G.L.
c. 152;
(k) a copy of the
applicant's latest annual report, certified by a public accountant.
(l) in any instance in which the applicant
intends to utilize an approved insurance company for servicing its claims, a
copy of an agreement prescribed by the Department and the Division of
Insurance, signed by the applicant and the insurance company, providing that
the signatories agree to be governed by the provisions of M.G.L. c. 176D and
any relevant regulations promulgated thereunder.
