Form WC18 "Employer's Application for Self Insurance" - Alabama

What Is Form WC18?

This is a legal form that was released by the Alabama Department of Labor - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2012;
  • The latest edition provided by the Alabama Department of Labor;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form WC18 by clicking the link below or browse more documents and templates provided by the Alabama Department of Labor.

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Download Form WC18 "Employer's Application for Self Insurance" - Alabama

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WC Form 18
Revised 10/12
EMPLOYER’S APPLICATION FOR SELF INSURANCE
(Submit one completed copy)
CONFIDENTIAL
To the DEPARTMENT OF LABOR:
The undersigned, an employer subject to the provisions of the Alabama Workers’ Compensation law, as last
amended, hereby applies for the privilege of self-insuring the payment of compensation provided in that law, and submits the
following facts under oath to the Department of Labor to enable it to determine if sufficient financial ability exists to render
certain the payment of such compensation:
1.
Name of Applicant _______________________________________________________________________
2.
Address
P.O. Box
(Number)
(Street)
(City or Town)
(County)
(State)
(Zip)
Telephone (
)
AL U.C. Number
EMPLOYER IDENTIFICATION NUMBER
3. The applicant is
(State whether individual, co-partnership, limited partnership, corporation, receiver or trustee)
T
4. briefly the general character of the operations performed and the articles manufactured or compounded at or away from
e
the plant or premises of the applicant.
l
e
p
h
o
n
e
5.
Description of employment:
(
Estimated average
Estimated average
Estimated payroll of all
Location of Plant or
Kind of Equipment
number of employees at
number of employees in
Alabama employees for
)
Plants
all points
Alabama
ensuing year
A
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.
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WC Form 18
Revised 10/12
EMPLOYER’S APPLICATION FOR SELF INSURANCE
(Submit one completed copy)
CONFIDENTIAL
To the DEPARTMENT OF LABOR:
The undersigned, an employer subject to the provisions of the Alabama Workers’ Compensation law, as last
amended, hereby applies for the privilege of self-insuring the payment of compensation provided in that law, and submits the
following facts under oath to the Department of Labor to enable it to determine if sufficient financial ability exists to render
certain the payment of such compensation:
1.
Name of Applicant _______________________________________________________________________
2.
Address
P.O. Box
(Number)
(Street)
(City or Town)
(County)
(State)
(Zip)
Telephone (
)
AL U.C. Number
EMPLOYER IDENTIFICATION NUMBER
3. The applicant is
(State whether individual, co-partnership, limited partnership, corporation, receiver or trustee)
T
4. briefly the general character of the operations performed and the articles manufactured or compounded at or away from
e
the plant or premises of the applicant.
l
e
p
h
o
n
e
5.
Description of employment:
(
Estimated average
Estimated average
Estimated payroll of all
Location of Plant or
Kind of Equipment
number of employees at
number of employees in
Alabama employees for
)
Plants
all points
Alabama
ensuing year
A
L
U
.
C
N
u
m
b
e
r
6. If a Corporation or Limited Partnership list below names of officers, directors, and residence of each:
NAME
OFFICIAL TITLE
ADDRESS
7. If a Limited Partnership, give date of formation and duration
8. If a Partnership, list below names of members and residence of each
9. If Individual, give name and residence
10. If a Corporation, answer the following: Chartered under the laws of the State of
Date of incorporation_____________________ Authorized Capital Stock: (Common) $
(Preferred) $
11. Is applicant a subsidiary? ________ Give name and address of parent company
(Subsidiaries must have separate applications and indemnity agreements)
12. If foreign corporation, give address of Home Office
13. Date when self-insurance is desired______________________________20_____12:01 a.m.
14. Are you now complying with Section 25-5-8 of the Law, by carrying workers’ compensation insurance on your
employees? If so, indicate the name of the insurance company (not local agent) with whom you are insured.
15. What is the expiration date of your present policy?__________________________________
16. Are you now, or have you been within the past three years, an assigned risk for workers’ compensation insurance? (Give
dates and details on separate page, if necessary)
17. As a self-insurer, will you deal directly with your employees in workers’ compensation matters, or through an approved
service organization? If the latter method is to be used, give name and address of the organization.
18. Past three-year Accident Experience:
__________
____________
____________
__________
____________
____________
Number of deaths
Alabama Workers’ Compensation Premiums
$_________
$___________
$____________
Alabama Workers’ Comp Incurred Losses
$_________
$___________
$____________
19. Are there any outstanding unpaid judgments subject to execution rendered against the applicant under the provisions of
the Workers’ Compensation Law, as last amended? (Give amounts and details on separate page, if necessary)
20. Applicant must attach audited or certified financial reports for the prior three years of operation.
21. Applicant must submit a $500.00 application fee with each application submitted.
Department of Labor Workers’ Compensation Administrative Trust Fund.
Make payable to:
22. Name of excess insurance carrier (if any)
Amount of Retention $
Specific, Aggregate, or both?
23. Relate facts, covering past three years:
Year Ending
Expenses (including
Payroll
Profit or Loss
Sales (Omit cents)
payroll)
(Specify)
20
20
20
24. Has the applicant, or its parent corporation, every filed for bankruptcy?
If yes, give details on separate sheet.
AGREEMENT CONDITIONS
25.
In consideration of the approval of this application, the applicant expressly agrees:
(a) That this privilege may be revoked at any time in the discretion of the Secretary of Labor as provided in Section 25-58 (d1) of said Law, as amended.
(b) That the applicant will promptly furnish adequate hospital, medical, surgical, and burial benefits within the limits of the Law.
(c) That the applicant will discharge liability for compensation to injured employees or their dependents in accordance with said Law’s requirements.
(d) That reports will be promptly furnished the Department in strict accordance with Sections 25-5-4, 25-5-5 and 25-5-7 of said law.
(e) That the applicant will not solicit, receive or collect from his employees, any part of the cost to him of operating under this Law.
(f) That the applicant will promptly notify the Department upon insuring his workers’ compensation liability with a private casualty insurance company,
thereby cancelling his self-insurance privileges.
(g) That a copy of the company’s annual report, or statement of assets and liabilities, will be mailed to the Department at the close of each fiscal year, as
evidence of continued financial ability to self-insure its liability under said Law.
(Signed)________________________________________
(Title)__________________________________________ STATE
OF ________________________________ COUNTY OF ______________________________
__________________________________, being first duly sworn, appeared personally and declared that the
facts set forth in the foregoing application are true to the best of his knowledge, information and belief. Subscribed
and sworn to before me, this __________ day of __________________________, 20_____
(SEAL) My commission
(Notary Public)
expires on the __________ day of _________________________, 20_____
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