Pennsylvania Code › Title 34 - LABOR AND INDUSTRY › Part VIII - Bureau of Workers' Compensation › Chapter 125 - WORKERS' COMPENSATION SELF-INSURANCE › Subchapter A - INDIVIDUAL SELF-INSURANCE › Section 125.3 - Application

Current through Register Vol. 54, No. 28, July 13, 2024
(a) An applicant
				  shall file an application on a form prescribed by and available upon request
				  from the Bureau. All questions on the application shall be answered completely
				  and accurately with the most recent information available. A rider may be
				  attached if more space is necessary. The application shall be signed by the
				  applicant, or if a corporation, an officer of the corporation. The application,
				  including any attached riders and applicable forms, shall be verified as set
				  forth on the application, subject to the penalties of
				  18 Pa.C.S. §
											4904
				  (relating to unsworn falsification to authorities).
(b) Initial applications shall be filed with
				  the Bureau no later than 3 months prior to the requested effective date of
				  self-insurance. Renewal applications shall be filed with the Bureau no later
				  than 3 months prior to the expiration of the current permit.
(c) With the application, the applicant shall
				  include:
(1) The nonrefundable statutory fee
				  in the amount of $500 for initial applicants or $100 for renewal applicants
				  required under section 305(a) of the act (77 P. S. §
												501(a)), payable to the
				  "Commonwealth of Pennsylvania." A statutory fee is required in the amount of
				  $500 for each affiliate or subsidiary being initially added or in the amount of
				  $100 for each affiliate or subsidiary renewing under a consolidated application
				  under §
											125.4 (relating to application for
				  affiliates and subsidiaries).
(2)
				  Its Securities and Exchange Commission (SEC) Form 10-K, or equivalent form
				  filed by a foreign corporation with the SEC or the governing body of an
				  internationally recognized public securities exchange for an application being
				  processed under the conditions of §
											125.4(e), for the
				  last complete fiscal year, if applicable. The filing of these forms does not
				  serve as a substitute for the full completion of the application
				  form.
(3) Its latest audited
				  financial statements issued by a licensed certified public accountant or
				  accounting firm. For a private employer, the audited financial statements must
				  cover the last complete fiscal-year period immediately prior to the date of
				  application. The audited financial statements must meet the following criteria:
(i) They must be presented in conformance
				  with applicable generally accepted accounting principles as promulgated by the
				  Financial Accounting Standards Board or the Government Accounting Standards
				  Board or with international financial reporting standards promulgated by the
				  International Accounting Standards Board. The text of the financial statements
				  and their accompanying notes must be in the English language. If the currency
				  used in the financial statements is not in United States dollars, the applicant
				  shall cooperate and assist the Bureau in converting the currency to United
				  States dollars.
(ii) They must be
				  audited in accordance with generally accepted auditing standards in the United
				  States or in accordance with the standards of the Public Company Accounting
				  Oversight Board (United States) or the International Standards on Auditing. An
				  unqualified or qualified opinion shall be stated on the most recent audited
				  financial statements.
(iii) If the
				  most current audited period precedes the application date by more than 6
				  months, the applicant's latest SEC Form 10-Q, or similar form filed by a
				  foreign corporation with the SEC or the governing body of an internationally
				  recognized public securities exchange for an application being processed under
				  the conditions of §
												125.4(e), or
				  unaudited interim financial statements must be submitted.
(4) Audited financial statements covering the
				  applicant's second and third most recent complete fiscal-year periods prior to
				  the date of the application, if an initial application. If audited financial
				  statements covering those periods are not available, financial statements
				  reviewed by a certified public accountant in accordance with standards
				  established by the American Institute of Certified Public Accountants or the
				  International Auditing and Assurance Standards Board covering the second and
				  third most recent complete fiscal year periods prior to the date of the
				  application will be accepted.
(5) A
				  report of the paid and incurred workers' compensation loss experience in this
				  Commonwealth under each of the 3 completed policy years prior to the
				  application of each employer requesting self-insurance, if an initial
				  application. The loss information for each policy year shall be valued within 3
				  months prior to the date of the submission of the application.
(6) A report on a form prescribed by the
				  Bureau and provided to each employer requesting self-insurance stating the
				  costs of claims incurred by the employer by annual periods and projecting the
				  total value of its outstanding liability under the act and the Occupational
				  Disease Act, if a renewal application. A renewal applicant that has retained
				  the services of an actuary to project the total value of its outstanding
				  liability may submit the actuary's report with its application.
(7) A report for each employer requesting
				  self-insurance on a form prescribed by the Bureau and provided to each employer
				  requesting self-insurance summarizing the existence of the accident and illness
				  prevention program required under section 1001(b) of the act (77 P. S. §
												1038.1) and regulations promulgated
				  thereunder.
(8) A listing for each
				  employer requesting self-insurance, in a Bureau-prescribed electronic format
				  provided to each employer requesting self-insurance, of the employer's
				  Pennsylvania workers' compensation claims incurred as a self-insurer, including
				  claims currently in litigation, and information such as payments and reserves
				  on each claim. The listing must include:
(i)
				  All open claims at the time of submission.
(ii) All claims closed on or after September
				  11, 2010.
(iii) Case reserves
				  provided in the listing must be established according to instructions on forms
				  prescribed by the Bureau and provided to each employer requesting
				  self-insurance.
(9)
				  Written verification of the applicant's current long-term credit or debt
				  ratings, if any.