806 KAR 52:010. Forms for application,

security deposits and financial statements.

 

      RELATES TO: KRS 304.50

      STATUTORY AUTHORITY: KRS 304.50-010(2),

304.50-030(1), 304.50-050(1), (2), 304.50-060(4)

      NECESSITY, FUNCTION, AND CONFORMITY: KRS

304.50-010(2) requires the executive director to promulgate administrative

regulations as necessary to govern admission, certification and regulation of

workers’ compensation self-insured groups. 304.50-030(1) requires a workers’

compensation self-insured group seeking initial certification to file an

application on a form approved by the executive director. KRS 304.50-050(1)

requires a workers’ compensation self-insured group to provide a security

deposit to the executive director on a form prescribed by the executive director.

KRS 304.50-050(2) allows trustees to file cash, cash equivalents, United States

Treasuries or a bank letter of credit in satisfaction of the security deposit

requirement, on a form prescribed by the executive director. KRS 304.50-060(4)

requires workers’ compensation self-insured groups to file statements of

financial condition on a form prescribed by the executive director. This

administrative regulation prescribes the required forms for application,

security deposits and financial statements.

 

      Section 1. Definitions. (1)

"Executive director" means the Executive Director of the Office of

Insurance.

      (2) "Office" means the Office

of Insurance.

      (3) "Self-Insured group" is

defined in KRS 304.50-015(29).

 

      Section 2. (1) Pursuant to KRS

304.50-030(1), Form 100, Initial Application for Certificate of Filing As a

Workers’ Compensation Self-Insured Group, shall be completed and submitted to

the executive director to apply for initial certification as a workers’ compensation

self-insured group.

      (2) Pursuant to KRS 304.50-050(5), Form

141, Election Form for Designation of Custodian Bank for Safekeeping of

Securities, shall be completed and submitted to the executive director to

propose designation of a bank or trust company for the safekeeping of securities.

      (3) Pursuant to KRS 304.50-050(2), Form

142, Letter of Credit, shall be completed and submitted to the executive

director when issuing a letter of credit in satisfaction of the security

deposit requirement for a workers’ compensation self-insured group.

      (4) Pursuant to KRS 304.50(2), Form 145,

Transaction Sheet for Securities Held Under Safekeeping with Designated

Custodian Banks, shall be completed and submitted to the executive director

when transferring funds in or out of the Safekeeping Account and shall be

approved by the executive director before the bank can complete the transfer.

      (5) Pursuant to KRS 304.50(2), Form 826,

Safekeeping Agreement for Workers’ Compensation Self-Insured Groups, shall be

completed and submitted to the executive director when the self-insured group

initially sets up the security account or when a group transfers the security

deposit to another bank.

      (6) Pursuant to KRS 304.50-060(4), the

Workers’ Compensation Self-Insured Group Quarterly Statement (Blank), shall be

completed and submitted to the executive director to file a quarterly statement

of financial condition. Form 102, Trustee Confirmation of Receipt, shall be

completed by each trustee of the workers’ compensation self-insured group,

acknowledging receipt of a copy of the quarterly statement of financial

condition, and submitted to the Office of Insurance within seventy-five (75)

calendar days after the close of each quarterly reporting period.

      (7) Pursuant to KRS 304.50-060(4), the

Workers’ Compensation Self-Insured Group Annual Statement (Blank), shall be

completed and submitted to the executive director to file an annual statement

of financial condition.

      (8) Pursuant to KRS 304.50-050(1), Form

147, Deposit Calculation for Workers’ Compensation Self-Insured Groups, shall

be completed and submitted annually to the executive director to calculate the

correct amount to be placed in the Safekeeping Account.

 

      Section 3. Incorporation by Reference.

(1) The following material is incorporated by reference:

      (a) "Form 100 - Initial Application

for Certificate of Filing As a Workers’ Compensation Self-Insured Group

(2005)";

      (b) "Form 141 - Election Form for

Designation of Custodian Bank for Safekeeping of Securities (2005)";

      (c) "Form 142 - Letter of Credit

(2005)";

      (d) "Form 145 - Transaction Sheet

for Securities Held Under Safekeeping with Designated Custodian Banks

(2005)";

      (e) "Form 826 - Safekeeping

Agreement for Workers’ Compensation Self-Insured Groups (2005)";

      (f) "Workers’ Compensation

Self-Insured Group Quarterly Statement (Blank) (July 15, 2005)";

      (g) "Form 102 - Trustee Confirmation

of Receipt (4/2005)";

      (h) "Workers’ Compensation

Self-Insured Group Annual Statement (Blank) (July 15, 2005)"; and

      (i) "Form 147 - Deposit Calculation

for Workers’ Compensation Self-Insured Groups (2005)".

      (2) This material may be inspected,

copied, or obtained, subject to applicable copyright law, at the Kentucky

Office of Insurance, 215 West Main Street, Frankfort, Kentucky 40601, Monday

through Friday, 8:00 a.m. to 4:30 p.m. This material is also available on the Office

of Insurance Internet Web site at http://doi.ppr.ky.gov/kentucky/. (31

Ky.R. 2065; 32 Ky.R. 276; 502; eff. 10-7-2005.)