ࡱ> -/,_ bjbj <bb>>>>>RRRRfRpzzzzzUUU$h>UUUUU>>zz*{{{U >z>z{U{{{z`_{@0p{{>{`UU{UUUUUUUUpUUUUUUUUUUUUU : STATE OF NEVADA WORKERS COMPENSATION SELF-INSURANCE REQUIREMENTS SEND APPLICATION TO: State of Nevada Division of Insurance Self-Insured Workers Compensation Section ATTN: Shirley Choma/Sherri Abeyta 1818 East College Parkway, Suite 103 Carson City, NV 89706 (775) 687-0776/(775) 687-0775 FILING FEE: $200.00 (NON-REFUNDABLE) APPLICATION: Employers Application for Self-Insurance (form) Initial application requires three (3) years of Audited financial statements of the applicant, if (3) years are available, and three (3) years of loss runs. QUALIFICATION REQUIREMENTS: Must have a tangible net worth of at least $2.5 million. If the employer demonstrates a strong financial position BUT FAILS TO MEET THE $2.5 MILLION TANGIBLE NET WORTH, an irrevocable letter of credit in the amount $2.5 million in lieu of the $2.5 million tangible net worth may be accepted. If the letter of credit is used as a substitute for the tangible net worth requirement, the security deposit may not be in the form of a letter of credit. Parents may be required to indemnify subsidiaries. SECURITY DEPOSIT: The greater of $100,000 or 105% of the employers expected annual incurred cost, in the form of a surety bond, negotiable securities backed by the full faith and credit of the United States, cash, or a letter of credit (from a federally insured financial institution). EXCESS INSURANCE: Required. Minimum self-insured retention is $100,000. Must be countersigned by a licensed Nevada agent and have a 60-day cancellation clause. ASSESSMENTS: Initial insolvency fund assessment = 0.50% of the security deposit. Annual Insolvency Fund = 0.25% of the security deposit CLAIMS ADMINISTRATION: Self-insured employers are permitted to self-administer their workers compensation claims. Otherwise, claims must be administered by a licensed third-party administrator. REPORTS REQUIRED: Annual audited financial statements of the employer due 120 days after employers fiscal year end. Employers Annual Claims Information Report is due on September 30 each year. CZo " # ) 6 7 8 = > F H W ` n q | + , O P # &   BCy ;Ͼ˺h+khq/ hk_>*hi^mhk_ hk_5h7hh7hIvhh"Xh h,@ hf5 hf5>*hfI&BCj $ G H p q O P  T # $a$gdq/gdk_gdk_ $^a$gdq/$a$#  Y =ij=C^gdq/gd+k ^`gd+k ^`gdk_gdq/gdk_^gdk_;BCNOUV\]hiohq/h+khk_ :PP&P:p"X/ =!"#$% ^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH 8`8 Normal_HmH sH tH 8@8  Heading 1$@&5DA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List 2>@2 Title$a$5>*PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] ; #  8@0(  B S  ?79#&%BE3333333333+NOO77jj+NOO77jj & ? &7q/,@"Xk_+ki^mrfMIvjo7h@@UnknownG*Ax Times New Roman5Symbol3. *Cx ArialA$BCambria Math"hTRTR&GMGM$24KHX  ?7h2!xx STATE OF NEVADAState of NevadaTerri ChambersOh+'0`    ( 4@HPXSTATE OF NEVADAState of Nevada Normal.dotmTerri Chambers2Microsoft Office Word@@z*@l[M@l[MGM՜.+,0 hp   Dept. of Business & Industry STATE OF NEVADA Title  !"#%&'()*+.Root Entry Fa$`01TableWordDocument<SummaryInformation(DocumentSummaryInformation8$CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q