Workers' Compensation Coverage Application

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					                                         Property, Liability, Workers’ Compensation and Employee Benefit Services

                                                                                           1212 Court St NE Salem, OR 97301
                                                                                             PH 503-763-3800 / 1-800-922-2684
                                                                                                            FAX 503-763-3900
Entity Name: ______________________________________


                                        Workers’ Compensation
                                         Coverage Application
Entity Information
 Date
 Contact Person
 Title
 Address
 City
 State
                                  Oregon
 Zip Code
 Telephone
 Fax
 E-Mail

Agent Information
 Agency Name
 Contact Person
 Title
 Address
 City
 State
                                   Oregon
 Zip Code
 Telephone
 Fax
 E-Mail



CIS Workers’ Compensation Application                                                                                      1
(A) General Information

Workers= Compensation Claims/Return-to-Work Contact Person:________________________________________
Payroll              Reporting             and             Financial            Information            Contact
Person:____________________________________________
Safety and Compliance Issues Contact Person:______________________________________________________
Send copies of Workers= Compensation loss reports to:_______________________________________________
Current Experience Modification: ______________         WCD Employer Number:_________________________
Oregon Business Identifications Number (BIN): ___________________________________________________


(B) Operational Information
1.        Has your entity had any operational changes or added new exposures not previously covered by workers’
          compensation? Yes ______ No ______

          If yes, please explain: ___________________________________________________________________
          ___________________________________________________________________________________
          ____________________________________________________________________________________

2.        Does your entity have employees or volunteers engaged in work at an airport? Yes ______ No ______

3.        Does your entity own, lease, or charter any aircraft? Yes ______ No ______
          If yes, please explain: ___________________________________________________________________
          ___________________________________________________________________________________
          ____________________________________________________________________________________

4.        Does your entity have employees or volunteers operate aircraft? Yes ______ No ______
          If yes, how many ______ and please explain: _________________________________________________
          ___________________________________________________________________________________
          ____________________________________________________________________________________

5.        Does your entity own, lease, or charter any watercraft? Yes ______ No ______
          If yes, please explain: ___________________________________________________________________
          ___________________________________________________________________________________
          ____________________________________________________________________________________

6.        Does your entity have employees or volunteers operate watercraft on a navigable waterway?
          Yes ______ No ______
          If yes, please explain: ___________________________________________________________________
          ___________________________________________________________________________________
          ____________________________________________________________________________________
7.    Does your entity own, operate, or maintain a railroad, or own, lease, operate or repair railroad equipment?
      Yes _______ No ________

8.    Does your entity have any occupational disease exposures involved in its operations (asbestos; silica;
      dusts, toxic, injurious, or hazardous chemicals; caustics, fumes, radiation, communicable diseases and any
      other O.D. exposures)? Yes ______ No ______
      If yes, please explain: ___________________________________________________________________
      ___________________________________________________________________________________
      ____________________________________________________________________________________

9.    Does your entity engage in the manufacturing, handling, transporting, distributing, or storing of explosives
      or explosive substances? Yes ______ No ______
      If yes, please explain: ___________________________________________________________________
      ___________________________________________________________________________________
      ____________________________________________________________________________________

10.   Does your entity perform any underground, subaqueous (taking place in or under water), or tunneling
      operations? Yes ______ No ______
      If yes, please explain: ___________________________________________________________________
      ___________________________________________________________________________________
      ____________________________________________________________________________________

11.   Does your entity perform any new construction/remodeling work using any of your own employees?
      Yes ______ No ______
      If yes, number of participating employees ______ and please explain scope of projects and duties of staff:
      ___________________________________________________________________________________
      ___________________________________________________________________________________
      ___________________________________________________________________________________

12.   Does your entity’s operation include the gutting, wrecking, or demolition of structures?
      Yes ______ No ______
      If yes, number of participating employees ______ and please explain: _____________________________
      ___________________________________________________________________________________
      ____________________________________________________________________________________
13.   Does your entity’s operation involve exposure to burns? Yes ______ No ______
      If yes, number of potential employees ______ and please explain: ________________________________
      ___________________________________________________________________________________
      ____________________________________________________________________________________

14.   Does your entity’s operation involve exposure to heights? Yes ______ No ______
      If yes, number of potential employees ______ and please explain: ________________________________
      ___________________________________________________________________________________
      ____________________________________________________________________________________
15.   Does your entity provide group transportation for employees to and from the workplace?
      Yes ______ No ______
      If yes, please explain: ___________________________________________________________________
      ___________________________________________________________________________________
      ____________________________________________________________________________________

16.   Has your entity ever been cited for any OSHA violations? Yes ______ No ______
      If yes, please explain: ___________________________________________________________________
      ___________________________________________________________________________________
      ___________________________________________________________________________________
      ___________________________________________________________________________________
      _____________________________________________________________________________________

17.   Does your entity use court-mandated workers for community service work crews?
      Yes ______ No ______
      1.     If yes, who is the sentencing court? __________________________________________________
      2.     Is your entity required to provide workers’ compensation coverage? Yes ______ No ______

18.   Does your entity use contract labor? Yes ______ No ______
      If yes, do you require Certificates of Workers’ Compensation Coverage? Yes ______ No ______

19.   Do the operations of your entity include volunteer or donated labor? Yes ______ No ______
      If yes, please explain: ___________________________________________________________________
      ___________________________________________________________________________________
      ___________________________________________________________________________________
      ___________________________________________________________________________________
      ____________________________________________________________________________________


20.   Describe any other special exposures. Coverage for unidentified exposures is subject to prior underwriting
      approval: __________________________________________________________________________
      ___________________________________________________________________________________
      ___________________________________________________________________________________
      ___________________________________________________________________________________
      ___________________________________________________________________________________
      ___________________________________________________________________________________
      ___________________________________________________________________________________

21.   In addition to the Entity Name shown in (A) General Information, list all Boards, Services Districts,
      Clubs and other public bodies created by the Entity and who are authorized to act on behalf of the
      Entity. Supply copies of ordinances, resolutions or documents of authority regarding each such
      organization:
     ___________________________________________________________________________________
     ___________________________________________________________________________________
     ___________________________________________________________________________________
     ___________________________________________________________________________________
     ___________________________________________________________________________________
     ___________________________________________________________________________________



PLEASE INCLUDE: (1)   Carrier loss runs valued as of March 31, for current plus last four policy
                      periods; and
                (2)   A copy of your most recent Experience Modification Worksheet (a sample
                      letter to order the worksheet from NCCI is included in this packet).
Entity Name: __________________________________________________                                Reference Code: N/A
                             ESTIMATE OF PAYROLL BY CLASSIFICATION

                                                                                          Estimated Employee
  Class                                  Description                                 and Assumed Volunteer Payroll*




No. of Employees:       Full-Time: ________     Part-Time : ________ Volunteer: ________

* If you elect coverage for your volunteer, please
         (1) Refer to your Volunteer Resolution (see sample) to determine what Assumed Wage to use;
         (2) Complete the Volunteer Election Form (see sample) for the correct Assumed Volunteer Payroll;
         (3) Transfer the Assumed Volunteer Payroll info to the table above.

                                     Return Application and relevant forms to:
                                            City County Insurance Services
                                                 1212 Court Street NE
                                                  Salem, OR 97301
                                                Phone: (800) 922-2684
                                                Fax: (503) 763-3900
                                            VOLUNTEER ELECTION FORM


Entity Name: ____________________________________                                     Coverage Year: ____________
CIS= ability to provide workers= compensation coverage for volunteers is directly related to each entity=s ability to keep verifiable
records of the names and hours worked by participants. Claims adjusters will verify coverage at the time a claim is filed.

(A) Public Safety Volunteers              (Code 8411, 8411F, 8411FC)
Column (1) - Using last year=s rosters, estimate the number of volunteer months for each position and enter the total on the
appropriate line in Column (1). Some volunteers are not active every month, i.e., one volunteer firefighter may be active five
months out of the year, two volunteer firefighters may be active 12 months out of the year, and five volunteer firefighters may be
active only one month out of the year. Thus, the number of volunteer firefighter months would be 34 (1 x 5 + 2 x 12 + 5 x 1).

Column (2) - Refer to your Volunteer Resolution before filling out the amounts in Column No. 2 below. Use an
assumed monthly wage of no less than $800 per volunteer per month (regardless if one day or 30 are worked) for contribution
payment and calculation of benefits. This assumed monthly wage may be increased at the entity’=s discretion in increments of
$100.


Multiply (1) x (2) = Estimated Assumed Payroll
       Volunteer Category                Class                 (1)                       (2)                   (1) x (2) = (3)
                                         Code              Est. No. of           Assumed Monthly                 Estimated
                                                           Volunteer                  Wage                    Assumed Payroll
                                                            Months*

Ambulance Driver                          8411
Ambulance Technician                      8411
Crime Prevention Unit                     8411
Sheriff                                   8411
Emergency Med Technician                  8411
Explorer Scout                            8411
Fire Chief/Asst. Fire Chief             8411FC
Firefighter                              8411F
Police Officer                            8411
Police Reserve                            8411
Probation Officer                         8411
Search and Rescue                         8411
Sheriff=s Posse                           8411
CERT/Quick Response                       8411
Other (please specify)                    8411
(B) Public officials on unpaid boards, commissions, and councils                       (Code 8742V)

CIS has designated Class Code 8742V for this type of exposure, if functions performed are strictly administrative,
clerical, no manual labor, reimbursed for expenses only and receive no remuneration. If you wish to provide
workers= compensation benefits, you may do so using an aggregate $2,500 assumed annual payroll amount for each Board,
Commission, and Council you elect to cover, regardless of how many officials are on each Board,
Commissions or Council.


                                   Type                                                                Estimated
      (City Council or Planning Commission or Budget Committee, etc.)                                  Assumed
                    If additional space is needed, please attach another sheet.                         Payroll
                                                                                                     ($2,500 each)




                                                                                      TOTAL:


(C) Public officials performing manual labor                    (Code 8742V)

CIS has designated Class Code 8742V for this type of exposure as well. Coverage for this exposure is available based on an
assumed monthly wage of $800 per month per public official.


                             Multiply (1) x (2) = Estimated Assumed Payroll
                                                                      (1)             (2)                  (3)
                         Position                                    No. of        Assumed             Estimated
                       (Mayor, etc.)                                Months         Monthly             Assumed
  If additional space is needed, please attach another sheet.       per year        Wage                Payroll
                                                                                    ($800)




                                                                                      TOTAL:
(D) Court–Mandated Community Service Workers/Inmates                               (Code 7720V)

If your entity uses workers from the correctional system (i.e., community service workers, inmates on work release, peer review
crews, etc.), it is important to clarify in writing who will provide workers= compensation coverage for these workers prior to work
inception. CIS recommends you obtain a Certificate of Coverage for Workers= Compensation from the sentencing court or
make arrangements to provide coverage through your own entity. If you are responsible for providing the workers=
compensation coverage, be sure to keep monthly time records for these workers and report them using Oregon minimum
hourly wage. CIS has designated Class Code 7720V for this type of exposure.

(E) All other volunteers (Codes – see below)

Assumed payroll for all other volunteer elections should be computed at Oregon minimum hourly wage times actual hours
worked and reported in the appropriate NCCI classification code with a suffix “V”. Unanticipated volunteer projects or exposure
can be added throughout the coverage year (1) by endorsement, (2) with advance notice to CIS, and (3) allowing two weeks for
processing. Coverage of this type cannot be backdated.


                          Multiply (1) x (2) x (3) x (4) = Estimated Assumed Payroll
      Volunteer Category                   NCCI        (1)              (2)           (3)             (4)              (5)
                                           Code    Est. No. of        No. of         No. of         Oregon         Estimated
                                                   Volunteers         Hours         Months         Minimum         Assumed
                                                   per month        per month       per year         Wage           Payroll


 Building Maintenance                      9015V
 Clerical                                  8810V
 Community Center                          9102V
 Court-Mandated Community                  7720V
 Service Workers

 Emergency Call Center                     8810V
 Garbage/Refuse                            9403V
 Interpreters                              8810V
 Janitorial                                9015V
 Library                                   8810V
 Lifeguards (pools)                        9015V
 Lifeguards (beaches & rivers)             9102V
 Meal Site Volunteers                      9079V
 Parks & Drivers                           9102V
 Public Health
 (please call CIS for proper class code)

 RV Park                                   9015V

CIS Workers’ Compensation Application                                                                                       9
 Senior Center                          9061V
 Sewer & Drivers                        7580V
 Sewer/Street Cleaning                  9402V
 Snow Removal                           9402V
 Street/Road Maintenance                5506V
 Waterworks & Drivers                   7520V
 Other (please specify)




CIS Workers’ Compensation Application           10
                                         YOUR ENTITY LETTERHEAD




Date



National Council on Compensation Insurance
Service Center
901 Peninsula Corporate Circle
Boca Raton, FL 33487

Re:     Request for Experience Modification Worksheet
        Risk ID No.: Your Entity to Fill This In

To Whom It May Concern:

Please release a copy of our July 1, 2XXX experience modification worksheet to:

                                 Your Entity Contact Name
                                 Your Entity Contact Title
                                 Your Entity Name
                                 Your Entity Fax No. _______________

Thank you.

Sincerely,



Your Entity Contact Person
Your Title




CIS Workers’ Compensation Application                                             11
                  CIS TRUST MEMBERSHIP PARTICIPATION AGREEMENT
                           APPLICATION FOR MEMBERSHIP

        WHEREAS,

        _______________ (entity name) wishes to participate in one or more Trust
        Programs offered by or through the CIS Trust.

        CIS Trust membership obligations and benefits are described in the CIS Trust
        Agreement, Bylaws and Rules

        Participation in a Trust Program offered by the CIS Trust is a contractual
        relationship between the Member and the Trust that incorporates the
        provisions of the Trust Agreement, Bylaws and Rules.

        The governing body of the prospective Member, or a person duly authorized
        to act on its behalf is being asked to acknowledge the availability of these
        documents and, if accepted for membership, their agreement to fulfill the
        Member Obligations described in Article 3 of the CIS Bylaws.

        THEREFORE, the undersigned represents as follows on behalf of (Member
        name):

                      I am a person duly authorized to act of behalf of the governing body
                      of the above named Member.
                      I acknowledge that I have access to the CIS Trust Agreement,
                      Bylaws and applicable Rules
                      I acknowledge that the above named Member, in participating in
                      one or more Trust Programs offered through CIS, agrees to be
                      bound by the terms and conditions described as Obligations of
                      Members in Article 3 of the CIS Bylaws.

        Date:

        Signed:

        Print or type name and Title:


        NJK May 2009



CIS Workers’ Compensation Application                                                        12