OAR 436-050-0270
Applying for Certification as a Self-Insured Employer Group: Private Employers


Employers applying for certification as a self-insured employer group must submit:


A completed Form 1867, “Application to Become a Self-Insured Employer Group: Private Employers;”


Proof in the form of a certificate from the Secretary of State’s Corporation Division showing the employer group as a corporation or cooperative;


A copy of the bylaws or corporate minutes that include:


Designation of specific individuals as trustees for the corporation or cooperative;


Naming an administrator to administer the financial affairs of the group who may not be a member of the group or the group’s board, or a trustee for the group; and


The criteria used by the trustees and administrator when approving applications for new membership and requests for withdrawal by members of the group;


A copy of the fidelity bond provided to the group by the administrator or a copy of the comprehensive crime policy obtained by the group, in an amount sufficient to protect the group against the misappropriation or misuse of any moneys or securities;


The current financial statements of each member making application demonstrating that the members meet the requirements of OAR 436-050-0260 (Qualifications of a Self-Insured Employer Group);


An individual report by employer showing the employer’s payroll by class and description and loss information for the last four calendar years;


A completed Form 1866, “Group Self-Insured Indemnity Agreement,” or another form authorized by the director, that jointly and severally binds each member for the payment of any compensation and moneys due to the director by the group or any member of the group. Government subdivisions do not need to submit this agreement;


Evidence of a safety and health loss prevention program designed to demonstrate that accident prevention will improve due to self-insurance;


Proof of an adequate staff qualified to process claims under OAR 436-050-0260 (Qualifications of a Self-Insured Employer Group)(5);


If applicable, a service agreement between the employer and service company that has been signed by both parties that meets the requirements of OAR 436-050-0210 (Notice of Self-Insurer’s Place of Business in State; Records Self-Insured Must Keep in Oregon)(2). The agreement must:


Be submitted at least 14 days before the desired date of certification, and approved by the director before the service company begins processing claims, regardless of the effective date established in the agreement; and


Contain the location, mailing address, telephone number, and any other contact information of the service company;


The type, retention and limitation levels of excess insurance the employers as a group are planning to obtain in accordance with OAR 436-050-0170 (Excess Insurance Requirements);


A procedure for notifying the director of:


The commencement or termination of employers within the group and the effect on the remaining combined net worth of the group; and


Arrangements made by an employer leaving the group to continue insurance coverage.


A program whereby each employer within the group contributes to a common claims fund in accordance with OAR 436-050-0300 (Self-Insured Employer Group, Common Claims Fund), or specification if the amount calculated under OAR 436-050-0300 (Self-Insured Employer Group, Common Claims Fund)(3) or (6) is to be included in the self-insured employer group’s security deposit; and


The type of security deposit the employer group wishes to provide, with appropriate justification.


Audited financial statements. Notwithstanding subsection (1)(e) of this rule, the director may require an audited financial statement before considering an application by a group for self-insurance.


Review of application. Within 60 days of receipt of all information required under this rule, the director will review the application and notify the employer group that the request for certification as a self-insured employer group is approved or denied:


If the request is denied, the employers will be notified of the reasons for denial; or


If the request is approved, the notice will include:


The amount of security deposit required;


Approval of the type, retention and limitation levels of the excess insurance as determined under OAR 436-050-0170 (Excess Insurance Requirements); and


Approval of the service agreement submitted under subsection (1)(j) of this rule.


Issuance of certification. If approved, the certification of self-insurance will be issued upon receipt of the security deposit and the appropriate excess insurance binder. The effective date of certification will be the first day of the month following the date the certification is issued, or a later date specified by the applicant.

Source: Rule 436-050-0270 — Applying for Certification as a Self-Insured Employer Group: Private Employers, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=436-050-0270.

Purpose and Applicability
Requests for Hearings or Administrative Review
Suspension and Revocation of Authorization to Issue Workers’ Compensation Insurance Policies
Service of the Notice of Civil Penalty Orders
Responsibility for Providing Coverage When a Contract is Awarded
Nonsubject Workers
Corporate Officers, Limited Liability Company Members, Partners
Extraterritorial Coverage
Notice of Insurer’s Place of Business in State
Records Insurers Must Keep in Oregon
Qualifications of a Self-Insured Employer
Applying for Certification as a Self-Insured Employer
Security Deposit Requirements
Excess Insurance Requirements
Annual Reporting Requirements
Determination of Amount of Self-Insured Employer’s Deposit
Qualifications for Deposit Exemption for Self-Insured Cities, Counties, and Qualified Self-Insured Employer Groups, Application Procedures, Conditions and Requirements, Revocation and Requalification
Using Self-Insured Employers’ Security Deposit/Self-Insured Employer Adjustment Reserve/Self-Insured Employer Group Adjustment Reserve/Director-Ordered Assessments of Private Employer Members of Self-Insured Employer Groups
Requirements for Changes in Self-Insured Employer Entity
Self-Insured Certification Cancellation
Notice of Self-Insurer’s Personal Elections
Notice of Self-Insurer’s Place of Business in State
Records Self-Insured Employer Must Keep in Oregon
Out-of-State Recordkeeping and Claims Processing by Self-Insured Employer
Qualifications of a Self-Insured Employer Group
Applying for Certification as a Self-Insured Employer Group: Private Employers
Applying for Certification as a Self-Insured Employer Group: Governmental Subdivisions
Commencement/Termination/Cancellation of Employers with a Self-Insured Employer Group
Self-Insured Employer Group, Common Claims Fund
Group Self-Insurance Revocation
Last Updated

Jun. 8, 2021

Rule 436-050-0270’s source at or​.us