SELF-INSURANCE APPLICATION FOR APPROVAL
A. An employer seeking approval to self-insure its liability under the Nebraska Workers' Compensation Act shall submit a written request for an application to the court. The written request for an application must be signed by a corporate officer and be on the employer's own letterhead. The employer requesting
an application must:
1. have 100 employees in Nebraska or reasonably expect to have 100 employees in Nebraska within one (1) year of beginning operations in Nebraska;
2. have a minimum of five (5) years in business under the present organizational structure, and;
3. be a corporation or political subdivision.
B. All questions on the application for approval to self-insure must be fully and accurately answered. Such answers shall be given under oath by an authorized officer of the applicant. Each application for approval to self-insure must be accompanied by:
1. a nonrefundable fee which has been determined in accordance with section 48-145.04(1);
2. copies of the applicant's certified financial statements for the last five years;
3. a current payroll report broken down by job classification code plus payroll reports broken down by job classification code for the four previous consecutive years;
4. incurred loss history for the last five years;
5. evidence of authorization to transact business in Nebraska or status as a political subdivision, and;
6. any other information, including supporting documentation, as requested by the court.
Sections48-145.04, RRS. 2010, and48-145, RS. Supp., 2016.
Effective date: April 25, 2002.