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.)