436-050-0160 Applying for Certification as a Self-Insured Employer (1) Required information. An employer applying for certification as a self-insured employer must submit: (a) A completed Form 1868, “Application for Self-Insurance;” (b) Proof of an adequate staff qualified to process the employer’s claims under OAR 436-050-0150(2); (c) The employer’s audited financial statements or audited annual reports for the last three fiscal or calendar years, subject to the following: (A) If the audited financial statements of a parent company are provided in place of statements for the employer, the director will not authorize the individual employer to be self-insured under its own program, unless a parental company guarantee can be obtained. Otherwise, it will be necessary for the parent company to be the self-insured employer or to separately insure the employer. In the context of this section, a parent company is a legal entity that owns a majority interest in the employer, or owns a majority interest in another entity or succession of entities that own a majority interest in the employer; or (B) If audited financial statements are not available at the time of application, the employer may submit certified financial statements in place of audited financial statements or annual reports. However, if the certified financial statements submitted are insufficient to evaluate the employer’s financial ability, the director may require the employer to submit audited financial statements; (d) The employer’s most recent experience rating modification worksheet and supporting documentation. Applicants with prior Oregon experience who do not submit this data will be assigned a 1.50 experience rating modification pending receipt of the data. All those without prior Oregon experience will be assigned a 1.00 experience rating modification; (e) The type, retention, and limitation levels of excess workers’ compensation insurance the employer is planning to obtain as required by OAR 436-050-0170; (f) If applicable, a service agreement between the employer and service company that has been signed by both parties that meets the requirements of OAR 436-050-0210. The agreement must: (A) Be submitted at least 14 days before the desired date of certification, and be 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; (g) Proof of the employer’s ability to provide an acceptable security deposit, including either: (A) Evidence from a surety bond company admitted to do surety business in this state that they will issue a surety bond for the employer, as Principal, and the Oregon Department of Consumer and Business Services, Workers’ Compensation Division, as Obligee; or (B) Evidence from a qualified bank that they will issue an irrevocable standby letter of credit for the employer with the Oregon Department of Consumer and Business Services as the beneficiary; (h) Evidence of an occupational safety and health loss control program in accordance with OAR 437-001 as required by ORS 656.430(10); and (i) Evidence of: (A) The employer’s authorization to do business in this state under ORS chapters 58, 60, 62, 63, 65, 67, 70, and 648, as applicable; or (B) The employer’s status as a municipal or public corporation as defined in ORS 297.405. (2) Review of application. Within 30 days of receipt of all information required in section (1) of this rule, the director will review the application and notify the employer that the request for certification as a self-insured employer is approved or denied. (a) If the request is denied, the notice will include the reason for denial; or (b) If the request is approved, the notice will include: (A) Confirmation of the type and the amount of the security deposit required; (B) Approval of the type, retention, and limitation levels of the excess insurance required; and (C) Approval of a service agreement submitted under OAR 436-050-0110, if applicable. (3) 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 first day of the month following the date the certificate is issued, or a later date specified by the applicant. Statutory/Other Authority: ORS 656.430 & 656.726(4) Statutes/Other Implemented: ORS 656.430 History: WCD 7-2022, amend filed 11/07/2022, effective 01/01/2023 WCD 5-2016, f. 11-28-16, cert. ef. 1-1-17 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 8-2003(Temp), f. & cert. ef. 7-18-03 thru 1-13-04 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 WCD 5-1985, f. 12-10-85, cert. ef. 1-1-86, Renumbered from 436-051-0310 WCD 7-1983, f. 12-22-83, cert. ef. 12-27-83 WCD 4-1982, f. 2-10-82, cert. ef. 2-15-82 WCD 3-1980, f. & cert. ef. 4-2-80