information must self-insurers report to the department? Each
self-insurer must provide the department:
(a) The name,
title, address and phone number of the single contact person who is the
liaison with the department in all self-insurance matters. This contact
will be sent all department correspondence and is responsible for
forwarding information to appropriate parties for timely action.
(b) A copy of its current policy of applying sick leave, health
and welfare benefits or any other compensation in conjunction with, or
as a substitute for, time loss benefits.
(2) When must
self-insurers notify the department of business status changes?
Self-insurers must notify the department in writing:
Immediately, of any plans to:
(i) Cease business entirely
or cease business in Washington; or
(ii) Dispose of
controlling financial interest of the original self-insurer. The
self-insurer must surrender its certificate for cancellation if
requested by the department.
(b) Within thirty days, of
(i) Amendment(s) or modification(s) to the
self-insurer's articles, charter or agreement of incorporation,
association, copartnership or sole proprietorship which will materially
change the business identity or structure originally certified.
(A) The department may require additional documentation.
(B) If the self-insurer becomes a subsidiary to another firm, the
parent must provide the department with its written guarantee on L&I
form F207-040-001 to assume responsibility for all workers'
compensation liabilities of the subsidiary if the subsidiary defaults on
its liabilities. See WAC 296-15-021
for additional information.
(ii) Separation (for example,
divestiture or spinoff) of any part of the original self-insurer.
(A) The original self-insurer remains responsible for claims
liability of the separated part up to the date of separation unless the
department approves an alternative.
(B) If the separating
part wishes to continue being self-insured, it must submit an
application for self-insurance certification (L&I Form F207-001-000)
to the department at least thirty days before separation.
(C) If certification cannot be granted before separation, industrial
insurance coverage must be purchased from the state fund effective the
date of separation.
(iii) Relocation, addition or closure
of physical locations.
(3) When must self-insurers
notify the department of administrative changes? A self-insurer
must notify the department in writing within ten days, of any change to
(a) Single contact person who is the liaison with the
department in all self-insurance matters. The self-insurer must include
the contact's title, address and phone number.
Contract with a service organization or third party administrator
independent of the self-insurer which will participate in the
self-insurer's responsibilities. The self-insurer must submit a copy of
the new or updated service contract. See WAC 296-15-021
for additional information.
(c) Administrator of its
workers' compensation program, if the self-insurer is self administered
instead of contracting with a service organization or third party
(4) What reports must self-insurers
submit to the department? Each self-insurer must submit:
(a) Complete and accurate quarterly reports summarizing worker
hours and claim costs paid the previous quarter. Self-insurers must use
a form substantially similar to the preprinted Quarterly Report for
Self-Insured Business, L&I form F207-006-000, form sent by the
department. This report is the basis for determining the
administrative, second injury fund, supplemental pension, asbestosis and
insolvency trust assessments. Payment is due by the date specified on
the preprinted report sent by the department.
hours must be reported as defined in chapter 296-17
WAC General reporting rules, audit and recordkeeping, rates and rating
system for Washington workers' compensation insurance.
Claim costs include, but are not limited to:
(A) Time loss
compensation. Include the amount of time loss the worker would have
been entitled to if kept on full salary.
partial disability (PPD) awards.
(C) Medical bills.
(E) Medical appliances.
(F) Independent medical examinations and/or consultations.
(G) Loss of earning power.
(H) Travel expenses for
treatment or rehabilitation.
(I) Vocational rehabilitation
(J) Penalties paid to injured workers.
(K) Interest on board orders.
(b) A complete and
accurate annual report of all claim costs paid for each year of
liability with an estimate of future claim costs. The self-insurer must
use a form substantially similar to the Annual Report for Self-Insured
Businesses (SIF-7), L&I form F207-007-000. This report is due March
1 of each year. The department uses this for the annual determination
of each self-insurer's surety requirement.
(c) A fully
audited financial statement within six months after the end of the
self-insurer's fiscal year. This report demonstrates the self-insurer's
continued ability to provide benefits and pay assessments as required.
The department will consider a written request for filing time
(i) This statement must be prepared by a
certified public accountant.
(ii) A self-insurer with a
parental guarantee may submit the parent's fully audited financial
statement if the parent's audited statement includes the financial
condition of all subsidiaries, including the self-insurer.
(iii) A political subdivision of the state may submit a state auditor's
report if it includes the self-insurer's audited financial statement.
If the state auditor does not audit the self-insurer annually, the
self-insurer must submit financial statements prepared internally for
any year a report by the state auditor is not available.
[Statutory Authority: RCW 51.14.077,
09-13-018, § 296-15-221, filed 6/5/09, effective 7/6/09. Statutory
Authority: RCW 51.14.077,
99-23-107, § 296-15-221, filed 11/17/99, effective 12/27/99.]