Oregon Administrative Rules › Chapter 436 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, WORKERS' COMPENSATION DIVISION › Division 50 - EMPLOYER/INSURER COVERAGE RESPONSIBILITY › Section 436-050-0280 - Applying for Certification as a Self-Insured Employer Group: Governmental Subdivisions

Current through Register Vol. 63, No. 7, July 1, 2024
(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 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
			 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.