436-050-0280 Applying for Certification as a Self-Insured Employer Group: Governmental Subdivisions (1) Required information. Governmental subdivisions applying for certification as a self-insured employer group must submit: (a) A completed Form 1867, “Application for Self-Insured Employer Group”; (b) Proof that the governmental subdivisions have formed: (A) An intergovernmental entity as provided under ORS 190.003 to 190.110; or (B) A self-insurance program under ORS 30.282(3); (c) An intergovernmental agreement that includes: (A) Designation of specific individuals as trustees for the group and naming an administrator to administer the financial affairs of the group; and (B) The criteria to be used by the trustees and administrator when approving applications for new membership and requests for withdrawal by members of the group; (d) A copy of the fidelity bond provided to the group by the administrator or a copy of the comprehensive crime policy obtained by the group, in an amount sufficient to protect the group against the misappropriation or misuse of any moneys or securities; (e) The current financial statements of each member making application, demonstrating the members meet the combined net worth requirement under OAR 436-050-0260; (f) An individual report by employer showing the governmental subdivision’s payroll by class and description and loss information for the last four calendar years; (g) A resolution by the governing body of each governmental subdivision binding it to be liable for the payment of any compensation and other amounts due to the director under ORS Chapter 656 incurred by that governmental subdivision during the period of group self-insurance; (h) Evidence of a safety and health loss prevention program designed to demonstrate that accident prevention will improve due to self-insurance; (i) Proof of an adequate staff qualified to process claims under OAR 436-050-0260(5); (j) If applicable, a service agreement between the group and service company that has been signed by both parties that meets the requirements of OAR 436-050-0210(2). The agreement must: (A) Be submitted at least 14 days before the desired date of certification, and approved by the director before the service company begins processing claims, regardless of the effective date established in the agreement; and (B) Contain the location, mailing address, telephone number, and any other contact information of the service company; (k) The type, retention and limitation levels of excess insurance the employers as a group are planning to obtain in accordance with OAR 436-050-0170; (l) A procedure for notifying the director of: (A) The commencement or termination of governmental subdivisions within the group and the effect on the remaining combined net worth of the group; and (B) Arrangements made by a governmental subdivision leaving the group to continue insurance coverage; (m) If applicable, a program whereby each employer within the group contributes to a common claims fund under OAR 436-050-0300, or specification that the amount calculated under OAR 436-050-0300(3) or (6) is to be included in the self-insured employer group’s security deposit; and (n) The type and amount of security deposit the group wishes to provide, with appropriate justification. In no case will the security deposit amount be less than $300,000. (2) Audited or certified financial statements. Notwithstanding (l)(e) of this rule, the director may require an audited or certified financial statement before considering an application by a group for self-insurance. (3) Review of application. Within 60 days of receipt of all information required in section (1) of this rule, the director will review the application and notify the group that the request for certification as a self-insured employer group is approved or denied. (a) If the request is denied, the notice will include the reasons for denial; or (b) If the request is approved, the notice will include: (A) The amount of the security deposit required; and (B) Approval of the type, retention and limitation levels of the excess insurance as determined under OAR 436-050-0170; and (C) Approval of the service agreement submitted under (1)(j) of this rule. (4) Issuance of certification. If approved, the self-insurance certification will be issued upon receipt of the security deposit, and the appropriate excess insurance binder. The effective date of certification will be the date the certification is issued, or a later date specified by the applicant. Statutory/Other Authority: ORS 656.407, ORS 656.430 & ORS 656.726(4) Statutes/Other Implemented: ORS 656.407 & ORS 656.430 History: WCD 7-2022, amend filed 11/07/2022, effective 01/01/2023 WCD 7-2017, amend filed 12/14/2017, effective 01/01/2018 WCD 5-2016, f. 11-28-16, cert. ef. 1-1-17 WCD 10-2014, f. 8-15-14, cert. ef. 9-15-14 WCD 6-2012, f. 10-4-12, cert. ef. 1-1-13 WCD 12-2003, f. 12-4-03, cert. ef. 1-1-04 WCD 5-2001, f. 6-22-01, cert. ef. 7-1-01 WCD 25-1990, f. 11-29-90, cert. ef. 12-26-90 WCD 7-1989, f. 12-22-89, cert. ef. 1-1-90 WCD 9-1987, f. 12-18-87, cert. ef. 1-1-88 WCD 9-1985, f. 12-12-85, cert. ef. 1-1-86