"Workers' Compensation Self-insurance Application" - Montana

Workers' Compensation Self-insurance Application is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • Released on March 29, 2022;
  • The latest edition currently provided by the Montana Department of Labor and Industry;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Labor and Industry.

ADVERTISEMENT
ADVERTISEMENT

Download "Workers' Compensation Self-insurance Application" - Montana

Download PDF

Fill PDF online

Rate (4.3 / 5) 11 votes
Renewal Date:
Montana Department of Labor & Industry
Employment Relations Division, Workers' Compensation Regulation Bureau
P.O.Box 8011
Helena, Montana 59604
Phone: (406) 444-7748 Fax: (406) 444-4140
Email: amber.weekes2@mt.gov
Website: Self-Insurance Plan 1
Date Stamp - Office Use Only
Workers' Compensation Self-Insurance Application for 2022
Complete this form in its entirety. Unanswered questions may delay processing.
Refer to the related instruction sheet on the above web site for details.
Check One:
New
Renewal
New member of existing group
Group Name:
If new, proposed effective date of self-insurance coverage:
GENERAL INFORMATION
Name of Company:
Date Established:
0
Date Company Started Business in Montana:
Address:
Federal Employer Tax ID #:
Parent Company :
Date Established:
Address:
Montana Operations (continue on separate sheet if necessary):
Number of
Legal Name
Employees Location
Nature of Business
1
2
3
4
Total Number of Montana employees
0
(Number of W-2's plus Volunteers)
Gross Montana Annual Payroll for CY 2021
$
-
Company Official(s) to Contact Regarding Self-Insurance:
Name
Title
Address
E-Mail
Phone No.
1
2
Company Official(s) to Contact Regarding Montana Operations:
Name
Title
Address
E-Mail
Phone No.
1
2
3
Workers Compensation Self-Insurance Application 2022 revised 3/29/22
Renewal Date:
Montana Department of Labor & Industry
Employment Relations Division, Workers' Compensation Regulation Bureau
P.O.Box 8011
Helena, Montana 59604
Phone: (406) 444-7748 Fax: (406) 444-4140
Email: amber.weekes2@mt.gov
Website: Self-Insurance Plan 1
Date Stamp - Office Use Only
Workers' Compensation Self-Insurance Application for 2022
Complete this form in its entirety. Unanswered questions may delay processing.
Refer to the related instruction sheet on the above web site for details.
Check One:
New
Renewal
New member of existing group
Group Name:
If new, proposed effective date of self-insurance coverage:
GENERAL INFORMATION
Name of Company:
Date Established:
0
Date Company Started Business in Montana:
Address:
Federal Employer Tax ID #:
Parent Company :
Date Established:
Address:
Montana Operations (continue on separate sheet if necessary):
Number of
Legal Name
Employees Location
Nature of Business
1
2
3
4
Total Number of Montana employees
0
(Number of W-2's plus Volunteers)
Gross Montana Annual Payroll for CY 2021
$
-
Company Official(s) to Contact Regarding Self-Insurance:
Name
Title
Address
E-Mail
Phone No.
1
2
Company Official(s) to Contact Regarding Montana Operations:
Name
Title
Address
E-Mail
Phone No.
1
2
3
Workers Compensation Self-Insurance Application 2022 revised 3/29/22
Workers' Compensation Self-Insurance Application for 2022
Page 2
ACCIDENT AND CLAIM SUMMARY
Claims reported on:
Policy Year
Fiscal Year
Calendar Year
Claim Year: beginning date
ending date
ACCIDENTS BY YEAR:
2021
2020
2019
2018
2017
# Medical Only
# of Lost Time
# of Fatal
TOTAL Accidents
Open Claims Only
<----- All Claims Open & Closed ----->
for Years
Prior to
ALL CLAIMS BY YEAR:
2021
2020
2019
2018
2017
2017
Total payments made: (line 1)
$
$
$
$
$
$
Unpaid reserves, without IBNR, as of
end of most recent year: (line 2)
$
$
$
$
$
$
Total incurred liability, without IBNR,
updated as of most recent year-end:
Sum of line 1 + line 2
$
$
$
$
$
$
Expected recoveries from excess
insurance carrier
$
$
$
$
$
$
When were Reserves last updated?
By Whom?
Three Year Average Incurred Liability (Use 2020, 2019, 2018):
$
Undiscounted Total Estimated UNPAID Liability On All Montana Claims:
For claims incurred before 7/1/89:
For claims incurred on or after 7/1/89:
(sum of line 2
above)
Total Claims:
$
0
$
0
Total Cash Paid During the Last Calendar Year (1/1/2021 - 12/31/2021):
Indemnity + Medical
+ Other
= Total
$
0
0
0
0
Medical payments in excess of $200,000 per claim during last calendar year
0
Workers Compensation Self-Insurance Application 2022 revised 3/29/22
Workers' Compensation Self-Insurance Application for 2022
Page 3
Are estimated unpaid compensation and medical liabilities included on company balance sheet?
Yes
No
If yes, how are they classified?
If no, explain.
Do you have a formal safety program?
Yes
No
Is there a Safety Engineer at Montana locations?
Yes
No
CLAIMS EXAMINER INFORMATION
Name of Montana Examiner
Phone
Address
E-Mail address
Location of Montana Claim Files
Third-Party-Administrator
(if applicable)
SECURITY & EXCESS INSURANCE INFORMATION
Surety Bond:
Name of Surety Company
Phone
Address
Bond Amount
$
Effective Date
Letter of Credit:
Name of Bank
Phone
Address
LOC Amount
$
Effective Date
Government Bond/Security:
Type of Bond/Security
Cusip#
Interest
0.00%
Maturity Date
Bond Amount
$
Effective Date
Certificate(s) of Deposit:
Name of Bank(s)
Certificate Number(s)
CD Amount(s)
$
$
$
Specific Excess Insurance:
Name of Insurance Carrier
Effective Date
Expiration Date
Self-Insured Retention (SIR)
$
Policy Limit
$
Deductible
$
Aggregate Excess Insurance:
Name of Insurance Carrier
Effective Date
Expiration Date
Self-Insured Retention (SIR)
$
Policy Limit
$
Workers Compensation Self-Insurance Application 2022 revised 3/29/22
Workers' Compensation Self-Insurance Application for 2022
Page 4
ELECTION AND CERTIFICATION
We hereby make application to be a self-insured employer in Montana and certify that all of the information
provided is correct. Our firm is an employer in the State of Montana. If we are granted self-insured status by
the Department, we agree to comply with and be bound by all of the applicable laws, rules, and regulations of
Montana pertaining to workers’ compensation and occupational disease.
We agree to notify the Department of Labor & Industry and the Montana Self-Insurers Guaranty Fund within 24
hours of the filing of any bankruptcy or determination of insolvency relating to this firm.
This election is made by the firm and authorized by the directors, officials, officers, by-laws, owner, or partners.
Typed Name
Title
Phone
Date
Authorized Signature
Typed Name
Title
Phone
Date
Authorized Signature
Workers Compensation Self-Insurance Application 2022 revised 3/29/22
Workers' Compensation Self-Insurance Application for 2022
Supplemental Page
Workers Compensation Self-Insurance Application 2022 revised 3/29/22
Page of 5