Form FIN477 "Texas Workers' Compensation Self-insurance Group (Sig) Excess Insurance Checklist" - Texas

What Is Form FIN477?

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

Form Details:

  • Released on December 1, 2016;
  • The latest edition provided by the Texas Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form FIN477 by clicking the link below or browse more documents and templates provided by the Texas Department of Insurance.

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Download Form FIN477 "Texas Workers' Compensation Self-insurance Group (Sig) Excess Insurance Checklist" - Texas

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FIN477 | 1216
TEXAS WORKERS’ COMPENSATION SELF-INSURANCE GROUP (SIG) EXCESS INSURANCE
CHECKLIST
Unless otherwise approved by the Commissioner of Insurance, a Self-Insurance Group shall obtain excess insurance for
losses that exceed a Group’s retention in an amount that will pay all benefits required under the Texas Labor Code and
28 Texas Administrative Code §5.6405. In no event, however, shall a SIG’s excess insurance coverage be less than $10
million per occurrence.
 Texas authorized/admitted insurer
Name:___________________________________________________________
OR
 Texas eligible surplus lines insurer
Name:__________________________________________________________
Please submit the following:
 SIG Notification form (FIN468)
 Copy of the proposed Excess Loss policy, renewal forms, certificates, endorsements and
any other amendments or applicable agreements/documents.
If an eligible Surplus Lines Carrier, please submit the following (a SIG cannot enter into an Excess Loss
arrangement with a Surplus Lines Carrier without Department prior approval):
 An affidavit signed by both the SIG and its agent, evidencing that accessing the non-
admitted market was done in compliance.
 Copy of AM Best report reflecting A- or better rating.
 Copy of Letter of Credit in compliance with 28 TAC §5.6405.
 Affidavit signed by both parties (SIG/Surplus Lines Carrier) that:
All related recoverable and receivables be collected within no later than 90 days.
The Department will be notified in no less than five (5) calendar days by the Group
upon its receipt a notice of cancellation/nonrenewal.
The Department will be notified in no less than thirty (30) calendar days prior to the
effective date of any proposed change in the excess insurance policy, by
endorsement or otherwise.
Texas Department of Insurance | www.tdi.texas.gov
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FIN477 | 1216
TEXAS WORKERS’ COMPENSATION SELF-INSURANCE GROUP (SIG) EXCESS INSURANCE
CHECKLIST
Unless otherwise approved by the Commissioner of Insurance, a Self-Insurance Group shall obtain excess insurance for
losses that exceed a Group’s retention in an amount that will pay all benefits required under the Texas Labor Code and
28 Texas Administrative Code §5.6405. In no event, however, shall a SIG’s excess insurance coverage be less than $10
million per occurrence.
 Texas authorized/admitted insurer
Name:___________________________________________________________
OR
 Texas eligible surplus lines insurer
Name:__________________________________________________________
Please submit the following:
 SIG Notification form (FIN468)
 Copy of the proposed Excess Loss policy, renewal forms, certificates, endorsements and
any other amendments or applicable agreements/documents.
If an eligible Surplus Lines Carrier, please submit the following (a SIG cannot enter into an Excess Loss
arrangement with a Surplus Lines Carrier without Department prior approval):
 An affidavit signed by both the SIG and its agent, evidencing that accessing the non-
admitted market was done in compliance.
 Copy of AM Best report reflecting A- or better rating.
 Copy of Letter of Credit in compliance with 28 TAC §5.6405.
 Affidavit signed by both parties (SIG/Surplus Lines Carrier) that:
All related recoverable and receivables be collected within no later than 90 days.
The Department will be notified in no less than five (5) calendar days by the Group
upon its receipt a notice of cancellation/nonrenewal.
The Department will be notified in no less than thirty (30) calendar days prior to the
effective date of any proposed change in the excess insurance policy, by
endorsement or otherwise.
Texas Department of Insurance | www.tdi.texas.gov
1/2
FIN477 | 1216
If the Group wishes to obtain excess insurance in an amount that is different that the amount
required by 28 TAC §5.6405(a), please submit the following:
 Supportive business plan that justifies the Excess Loss proposal, including but not
limited to current market conditions, a SIG’s size, types of employment, years in existence, and risk
exposure that might make compliance with 28 TAC §5.6405. Please include any additional financial
security available to the group or any other relevant factors that give a level of assurance that the
proposed Excess Loss structure is adequate.
Texas Department of Insurance | www.tdi.texas.gov
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