Group Funded Workers' Compensation Pool Annual Information Requirement.

Please have this submitted to the Kansas Insurance Department by April 1 of each year.

1. The pool is required to have a combined net worth of all pool members of at least $1,000,000 per K.S.A. 44-582(a)(6).

2. The pool is required to maintain the financial capability to meet outstanding liabilities per K.S.A. 44-582(a)(7).

3. The pool's annual Kansas gross premium of your pool is at least $250,000 per K.S.A. 44-582(a)(8).

4. Each member is required to have paid not less than 25% of their estimated annual premium that has been placed into the designated depository per K.S.A. 44-582(a)(10)(A).

5. Specific and aggregate excess insurance is currently in effect per K.S.A. 44-582(13).

6. The pool administrator is required to furnish a fidelity bond to the pool to comply with K.S.A. 44-591(a).

7. The pool is required to maintain at least two accounts; a claims fund account, which is required to have sufficient balance to meet any loss requirements contained within the aggregate excess policy, and an administrative account. Only disbursements that are credited toward the aggregate loss requirement may be made from the claims fund account per K.S.A. 44-591(b).

8. At least 70% of the annual premium shall go to the claims fund account per K.S.A. 44-585(b).

9. The service agent and its employees are covered by a fidelity bond to comply with K.S.A. 44-591(b).

10. The total amount of money paid or payable in workers' compensation claims by the pool in the preceding calendar year.

11. Has the list of pool members changed in the preceding year?

12. Have any changes occurred in your Indemnity Agreement, underwriting, safety engineering, claims adjusting, or reporting of loss data which may have occurred since the original application or the immediately preceding renewal application? K.S.A. 44-584(a) and 44-582(a)(9-12).

13. Please state the name and qualifications of the current pool administrator.

Additionally, the pool will notify the Kansas Insurance Department of any change in administrator within 30 days of such change.

14. The pool will notify the Commissioner within 10 days if a member terminates or the pool cancels a membership. The pool will maintain coverage of the terminated/cancelled member for 30 days after notice to the Commissioner or until the Commissioner give notice that the former member has procured workers' compensation and employer's liability insurance elsewhere, whichever occurs first. K.S.A. 44-590(b).

15. The pool will notify the Commissioner of any change in bylaws within 30 days of such change per K.S.A. 44-582(a)(1).

16. The pool will notify the Commissioner of any change in the trust agreement within 30 days of such change per K.S.A. 44-582(a)(2).

17. The pool notify the Commissioner of any change in the address of books and records within 30 days of such change per K.S.A. 44-582(a)(4).

18. The pool will provide an audited financial statement within 150 days after end of the pool's fiscal year per K.S.A. 44-584(c).

19. The pool is not borrowing any money in the name of the pool without advising the Commissioner K.S.A. 44-591(e).

20. The pool shall submit financial statements as the Commissioner may require per K.S.A. 44-584(c). Currently, those statements are collected quarterly by the Insurance Department's Financial Surveillance Division.

21. In accordance with K.S.A. 44-588, the pool is required to pay a 1% tax on the annual Kansas Gross Premium relating to the preceding calendar year.

Please send exhibits evidencing compliance with the above to Please number the exhibits to correspond with numbered requirements (i.e., label exhibits evidencing net worth of members as either 1 or 1.a. if multiple documents are necessary.)

Person responsible for completion of this form: