Code of Massachusetts Regulations › 452 CMR - DEPARTMENT OF INDUSTRIAL ACCIDENTS › Title 452 CMR 5.00 - Self Insurers › Section 5.02 - Licensing of Self Insurers

Current through Register 1525, July 5, 2024
(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.