(1) Every employer desiring to be licensed as a self-insurer shall make application therefore on forms provided by the department. The application shall be in such form as the Department may provide and shall contain such information as the Department may require. Employers shall, upon request of the Department, furnish such additional information as the Department may require. Except as provided by any law to the contrary, any information shall be confidential and used only for the purpose of determining the ability of the employer to be a self-insurer. A new application shall be filed with the department at least 90 days prior to the proposed effective date of said license; a renewal application shall be filed at least 60 days prior to the renewal date.

(2) In addition to the above, each applicant shall furnish to the Department:



(a) a sworn, itemized statement of the assets and liabilities of the applicant, separately showing assets owned in the Commonwealth;

(b) a payroll report for the preceding fiscal year and expected payroll for the next fiscal year along with the total number of persons employed by the applicant in the Commonwealth;

(c) a detailed description of the nature and kind of business carried on by the applicant in the Commonwealth including the legal status of the applicant and its status as a subsidiary or other affiliate of any other business entity;

(d) the location of the applicant's home address, principal office and all offices and locations in the Commonwealth, including mailing addresses and contact persons;

(e) a list of the names and addresses of owners, partners, officers and directors of the applicant including the name(s) of in-state residents for purposes of service of process;

(f) a report showing the name of the applicant's reinsurers, the effective dates of the policies, whether the reinsurance is specific or aggregate and the minimum and maximum amount of such coverage;

(g) the amount, if any, of outstanding workers' compensation liabilities, both incurred and paid, of previous policy years. A new application must list the previous three years of premium, losses and experience modification factors. A renewal application will show the complete loss experience for the prior four years if self insured for that period;

(h) evidence that the applicant has complied with MGL c.152, § 25A(2) and 452 CMR 5.03;

(i) evidence that the corporate policy of the applicant is to comply with OSHA safety requirements;

(j) a report showing arrangements made by the applicant for the handling of work related injuries in conformity with MGL c.152;

(k) a copy of the applicant's latest annual report, certified by a public accountant.

(l) in any instance in which the applicant intends to utilize an approved insurance company for servicing its claims, a copy of an agreement prescribed by the Department and the Division of Insurance, signed by the applicant and the insurance company, providing that the signatories agree to be governed by the provisions of MGL c.176D and any relevant regulations promulgated thereunder.