Current through Register Vol. 54, No. 44, November 2, 2024
(a) An applicant
shall file an application on a form prescribed by and available upon request
from the Bureau. All questions on the application shall be answered completely
and accurately with the most recent information available. A rider may be
attached if more space is necessary. The application shall be signed by the
applicant, or if a corporation, an officer of the corporation. The application,
including any attached riders and applicable forms, shall be verified as set
forth on the application, subject to the penalties of
18 Pa.C.S. §
4904
(relating to unsworn falsification to authorities).
(b) Initial applications shall be filed with
the Bureau no later than 3 months prior to the requested effective date of
self-insurance. Renewal applications shall be filed with the Bureau no later
than 3 months prior to the expiration of the current permit.
(c) With the application, the applicant shall
include:
(1) The nonrefundable statutory fee
in the amount of $500 for initial applicants or $100 for renewal applicants
required under section 305(a) of the act (77 P. S. §
501(a)), payable to the
"Commonwealth of Pennsylvania." A statutory fee is required in the amount of
$500 for each affiliate or subsidiary being initially added or in the amount of
$100 for each affiliate or subsidiary renewing under a consolidated application
under §
125.4 (relating to application for
affiliates and subsidiaries).
(2)
Its Securities and Exchange Commission (SEC) Form 10-K, or equivalent form
filed by a foreign corporation with the SEC or the governing body of an
internationally recognized public securities exchange for an application being
processed under the conditions of §
125.4(e), for the
last complete fiscal year, if applicable. The filing of these forms does not
serve as a substitute for the full completion of the application
form.
(3) Its latest audited
financial statements issued by a licensed certified public accountant or
accounting firm. For a private employer, the audited financial statements must
cover the last complete fiscal-year period immediately prior to the date of
application. The audited financial statements must meet the following criteria:
(i) They must be presented in conformance
with applicable generally accepted accounting principles as promulgated by the
Financial Accounting Standards Board or the Government Accounting Standards
Board or with international financial reporting standards promulgated by the
International Accounting Standards Board. The text of the financial statements
and their accompanying notes must be in the English language. If the currency
used in the financial statements is not in United States dollars, the applicant
shall cooperate and assist the Bureau in converting the currency to United
States dollars.
(ii) They must be
audited in accordance with generally accepted auditing standards in the United
States or in accordance with the standards of the Public Company Accounting
Oversight Board (United States) or the International Standards on Auditing. An
unqualified or qualified opinion shall be stated on the most recent audited
financial statements.
(iii) If the
most current audited period precedes the application date by more than 6
months, the applicant's latest SEC Form 10-Q, or similar form filed by a
foreign corporation with the SEC or the governing body of an internationally
recognized public securities exchange for an application being processed under
the conditions of §
125.4(e), or
unaudited interim financial statements must be submitted.
(4) Audited financial statements covering the
applicant's second and third most recent complete fiscal-year periods prior to
the date of the application, if an initial application. If audited financial
statements covering those periods are not available, financial statements
reviewed by a certified public accountant in accordance with standards
established by the American Institute of Certified Public Accountants or the
International Auditing and Assurance Standards Board covering the second and
third most recent complete fiscal year periods prior to the date of the
application will be accepted.
(5) A
report of the paid and incurred workers' compensation loss experience in this
Commonwealth under each of the 3 completed policy years prior to the
application of each employer requesting self-insurance, if an initial
application. The loss information for each policy year shall be valued within 3
months prior to the date of the submission of the application.
(6) A report on a form prescribed by the
Bureau and provided to each employer requesting self-insurance stating the
costs of claims incurred by the employer by annual periods and projecting the
total value of its outstanding liability under the act and the Occupational
Disease Act, if a renewal application. A renewal applicant that has retained
the services of an actuary to project the total value of its outstanding
liability may submit the actuary's report with its application.
(7) A report for each employer requesting
self-insurance on a form prescribed by the Bureau and provided to each employer
requesting self-insurance summarizing the existence of the accident and illness
prevention program required under section 1001(b) of the act (77 P. S. §
1038.1) and regulations promulgated
thereunder.
(8) A listing for each
employer requesting self-insurance, in a Bureau-prescribed electronic format
provided to each employer requesting self-insurance, of the employer's
Pennsylvania workers' compensation claims incurred as a self-insurer, including
claims currently in litigation, and information such as payments and reserves
on each claim. The listing must include:
(i)
All open claims at the time of submission.
(ii) All claims closed on or after September
11, 2010.
(iii) Case reserves
provided in the listing must be established according to instructions on forms
prescribed by the Bureau and provided to each employer requesting
self-insurance.
(9)
Written verification of the applicant's current long-term credit or debt
ratings, if any.
(d) The
applicant shall provide additional data, information and explanation that the
Bureau deems pertinent to its review of the application based on the factors
enumerated under §
125.6(a)
(relating to decision on application), and shall make any corrections
determined necessary by the Bureau, and provide any items under subsection (c)
determined missing or insufficient by the Bureau. The applicant shall provide
the data, information, explanation, corrections or missing items within 21 days
of its receipt of written notification from the Bureau of its need to do so, or
by a later date if requested by the applicant and approved by the Bureau. If
the applicant does not provide the data, information, explanation, corrections
or missing items within the prescribed time period, the application will be
deemed withdrawn. A renewal applicant that does not provide the data,
information, explanation, corrections or missing items within the prescribed
time period shall obtain workers' compensation insurance coverage effective the
expiration of that time period and shall provide evidence of the coverage, such
as a certificate of insurance, to the Bureau no later than the coverage's
effective date.
(e) The Bureau will
not issue a decision on the application under §
125.6 until the application,
including all items required under subsection (c) and all additional data,
information, explanation and corrections under subsection (d), have been
submitted.
(f) An initial
applicant's requested self-insurance effective date is subject to the approval
of the Bureau. An initial applicant which fails to insure its liability pending
review of its application will be subject to prosecution under the act and the
Occupational Disease Act.
The provisions of this §125.3 amended under sections
305(a) and 435(a) of the Workers' Compensation Act (77 P. S. §§
501 and
991(a)) and section 2205 of
The Administrative Code of 1929 (71 P. S. §
565).
This section cited in 34 Pa. Code §
125.4 (relating to application for
affiliates and subsidiaries); 34 Pa. Code §
125.6 (relating to decision on
application); and 34 Pa. Code §
125.7 (relating to
permit).
