Arizona Administrative Code › Title 20 - COMMERCE, FINANCIAL INSTITUTIONS, AND INSURANCE › Chapter 05 - INDUSTRIAL COMMISSION OF ARIZONA › Article 15 - WORKERS' COMPENSATION SELF-INSURANCE › Section R20-5-1506 - Renewal Application Requirements

Current through Register Vol. 30, No. 28, July 12, 2024
A. A Self-Insurer seeking to apply for
				renewal of authority to self-insure shall file with the Division a completed
				Self-Insurance Renewal Application Form and the documentation and information
				required under subsection (B) on or before the Renewal Date or, if applicable,
				the date specified in subsection (D).
B. For a renewal application to be deemed
				complete, the following documentation and information shall be provided by the
				Applicant:
1. A copy of the Applicant's
				most-recent audited financial statements completed according to R20-5-1513(A),
				including any notes to the financial statement.
2. A completed Workers' Compensation
				Liability Form.
3. A current loss
				run of all open claims incurred in Arizona on or after the Authorization Date.
				The loss run must include the following information, if applicable, for each
				claim: Payroll Classification Code, Commission claim number, employee name,
				date of injury, total paid medical, medical reserves, total paid indemnity
				(including death benefits), indemnity reserves, excess insurance carrier name
				(if applicable), amount of excess credit expected (if applicable), and excess
				insurance self-insured retention amount per occurrence (if
				applicable).
4. If applicable,
				copies of excess insurance policies that meet the requirements of R20-5-1526 or
				written confirmation from an authorized insurance company that it will provide
				excess insurance coverage to the Applicant. For each claim accepted by an
				excess insurance carrier on or after the Authorization Date, documentation to
				establish claim acceptance. For each claim submitted to an excess insurance
				carrier that is pending review by the excess insurance carrier, documentation
				to establish claim submission.
5.
				If the Applicant's Experience Modification Rate specific to Arizona for the
				most recent complete fiscal year is greater than 1.10, a written statement
				describing the causes of the inflated Experience Modification Rate and
				outlining remedial measures the Applicant has taken and will take to lower the
				Experience Modification Rate.
6. If
				the Applicant's denial rate exceeds 12% of claims filed during the prior
				approved period of self-insurance, a written statement from the Applicant
				identifying the reason or reasons for each denial.
7. Except for Applicants that have been
				approved to Self-Administer or are seeking to Self-Administer under R20-5-1510,
				a copy of the signed agreement between the Self-Insurer and a Third-Party
				Administrator, if different from the last filing approved by the
				Commission.
8. If an Applicant
				intends to Self-Administer, regardless of whether the Applicant has been
				previously approved to Self-Adminis-ter, a completed Application to
				Self-Administer Form and current information and documentation required under
				R20-5-1510(C).
9. If an eligible
				Applicant directs or intends to direct medical care under A.R.S. §
				23-1070, a completed Self-Provider of Medical Benefits Form, the detailed
				statement of the arrangements required in A.R.S. § 23-1070(B), and a copy
				of the current medical or hospital agreements, if applicable.
10. If the Applicant is a Public Entity or a
				Public Entity Pool that is seeking a waiver of security under R20-5-1525, a
				completed Request for Waiver of Security Form and a current actuarial report
				that satisfies the requirements in R20-5-1513(B).
11. If the Applicant is a Subsidiary, a copy
				of the Parent Company's most-recent audited financial statements, including any
				notes to the financial statements. If audited financial statements are not
				reasonably available, internally-reviewed and signed financial statements that
				conform with Generally Accepted Accounting Principles may be
				substituted.
12. If the Applicant
				is a Subsidiary and the Parent Company has changed since the last application
				or renewal approved by the Commission:
a. A
				completed Parent Guaranty Form or Agreement to Process and Pay signed by a
				designated representative of the Parent Company that guarantees the payment of
				the Subsidiary's obligations.
b. A
				resolution of the Parent Company's board of directors or governing body
				authorizing the designated representative to complete, sign, and file the
				Parent Guaranty Form or Agreement to Process and Pay. If a Parent Company does
				not have a board of directors or governing body, an authorized representative
				shall sign the resolution.
13. If the Applicant is a Self-Insurance
				Pool:
a. Updated copies of the documentation
				and information required in R20-5-1505(B)(13)(a) through (c), (g), and (h), if
				changed since the last filing approved by the Commission.
b. A current actuarial report that meets the
				requirements of R20-5-1513(B).
c.
				An original or a certified copy of the Self-Insurance Pool's current fidelity
				or crime insurance policy that meets the requirements of R20-5-1528.