Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 50 - EMPLOYER/INSURER COVERAGE RESPONSIBILITY › Section 436-050-0270 - Applying for Certification as a Self-Insured Employer Group: Private Employers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Employers
			 applying for certification as a self-insured employer group must submit:
(a) A completed Form 1867, "Application to
			 Become a Self-Insured Employer Group: Private Employers;"
(b) Proof in the form of a certificate from
			 the Secretary of State's Corporation Division showing the employer group as a
			 corporation or cooperative;
(c) A
			 copy of the bylaws or corporate minutes that include:
(A) Designation of specific individuals as
			 trustees for the corporation or cooperative;
(B) Naming an administrator to administer the
			 financial affairs of the group who may not be a member of the group or the
			 group's board, or a trustee for the group; and
(C) The criteria 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 that the members meet the requirements
			 of OAR 436-050-0260;
(f) An individual report by employer showing
			 the employer's payroll by class and description and loss information for the
			 last four calendar years;
(g) A
			 completed Form 1866, "Group Self-Insured Indemnity Agreement," or another form
			 authorized by the director, that jointly and severally binds each member for
			 the payment of any compensation and moneys due to the director by the group or
			 any member of the group. Government subdivisions do not need to submit this
			 agreement;
(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 employer 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
			 employers within the group and the effect on the remaining combined net worth
			 of the group; and
(B) Arrangements
			 made by an employer leaving the group to continue insurance coverage.
(m) A program whereby each
			 employer within the group contributes to a common claims fund in accordance
			 with OAR 436-050-0300, or specification
			 if 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 of security deposit the employer
			 group wishes to provide, with appropriate justification.