Ariz. Admin. Code § 20-5-1506

Current through Register Vol. 30, No. 50, December 13, 2024

Section R20-5-1506 - Renewal Application Requirements

A. A Self-Insurer seeking to apply for renewal of authority to self-insure shall file with the Division a completed Self-Insurance Renewal Application Form and the documentation and information required under subsection (B) on or before the Renewal Date or, if applicable, the date specified in subsection (D).

B. For a renewal application to be deemed complete, the following documentation and information shall be provided by the Applicant:

1. A copy of the Applicant's most-recent audited financial statements completed according to R20-5-1513(A), including any notes to the financial statement.

2. A completed Workers' Compensation Liability Form.

3. A current loss run of all open claims incurred in Arizona on or after the Authorization Date. The loss run must include the following information, if applicable, for each claim: Payroll Classification Code, Commission claim number, employee name, date of injury, total paid medical, medical reserves, total paid indemnity (including death benefits), indemnity reserves, excess insurance carrier name (if applicable), amount of excess credit expected (if applicable), and excess insurance self-insured retention amount per occurrence (if applicable).

4. If applicable, copies of excess insurance policies that meet the requirements of R20-5-1526 or written confirmation from an authorized insurance company that it will provide excess insurance coverage to the Applicant. For each claim accepted by an excess insurance carrier on or after the Authorization Date, documentation to establish claim acceptance. For each claim submitted to an excess insurance carrier that is pending review by the excess insurance carrier, documentation to establish claim submission.

5. If the Applicant's Experience Modification Rate specific to Arizona for the most recent complete fiscal year is greater than 1.10, a written statement describing the causes of the inflated Experience Modification Rate and outlining remedial measures the Applicant has taken and will take to lower the Experience Modification Rate.

6. If the Applicant's denial rate exceeds 12% of claims filed during the prior approved period of self-insurance, a written statement from the Applicant identifying the reason or reasons for each denial.

7. Except for Applicants that have been approved to Self-Administer or are seeking to Self-Administer under R20-5-1510, a copy of the signed agreement between the Self-Insurer and a Third-Party Administrator, if different from the last filing approved by the Commission.

8. If an Applicant intends to Self-Administer, regardless of whether the Applicant has been previously approved to Self-Adminis-ter, a completed Application to Self-Administer Form and current information and documentation required under R20-5-1510(C).

9. If an eligible Applicant directs or intends to direct medical care under A.R.S. § 23-1070, a completed Self-Provider of Medical Benefits Form, the detailed statement of the arrangements required in A.R.S. § 23-1070(B), and a copy of the current medical or hospital agreements, if applicable.

10. If the Applicant is a Public Entity or a Public Entity Pool that is seeking a waiver of security under R20-5-1525, a completed Request for Waiver of Security Form and a current actuarial report that satisfies the requirements in R20-5-1513(B).

11. If the Applicant is a Subsidiary, a copy of the Parent Company's most-recent audited financial statements, including any notes to the financial statements. If audited financial statements are not reasonably available, internally-reviewed and signed financial statements that conform with Generally Accepted Accounting Principles may be substituted.

12. If the Applicant is a Subsidiary and the Parent Company has changed since the last application or renewal approved by the Commission:

a. A completed Parent Guaranty Form or Agreement to Process and Pay signed by a designated representative of the Parent Company that guarantees the payment of the Subsidiary's obligations.

b. A resolution of the Parent Company's board of directors or governing body authorizing the designated representative to complete, sign, and file the Parent Guaranty Form or Agreement to Process and Pay. If a Parent Company does not have a board of directors or governing body, an authorized representative shall sign the resolution.

13. If the Applicant is a Self-Insurance Pool:

a. Updated copies of the documentation and information required in R20-5-1505(B)(13)(a) through (c), (g), and (h), if changed since the last filing approved by the Commission.

b. A current actuarial report that meets the requirements of R20-5-1513(B).

c. An original or a certified copy of the Self-Insurance Pool's current fidelity or crime insurance policy that meets the requirements of R20-5-1528.

C. A complete renewal application submitted to the Division before the Self-Insurer's Renewal Date shall serve to extend existing authority to self-insure until the earliest of the following:

1. The date the Commission takes action on the application according to R20-5-1509;

2. The date the Self-Insurer terminates self-insurance under R20-5-1518; or

3. The date the renewal application is withdrawn.

D. Upon written request, the Commission may temporarily extend the duration of an existing authorization to self-insure for up to 90 days after a designated Renewal Date if the Self-Insurer is working in good faith to file a complete renewal application with the Division and additional time is necessary to file a complete renewal application.

E. If a Self-Insurer does not file a complete renewal application on or before the Renewal Date or the date specified in subsection (D), if applicable, or a renewal application is deemed withdrawn, self-insurance authority ceases and the individual employer or each member of the pool shall provide the Commission proof of compliance with A.R.S. § 23-961(A) not later than 10 days after the SelfInsurer's Renewal Date, the date specified in subsection (D), or the date the renewal application is withdrawn, whichever is later.

Ariz. Admin. Code § R20-5-1506

New section made by final rulemaking at 28 A.A.R. 3435, effective 10/5/2022.