Group Funded Workers' Compensation Pool Annual Information Requirement.

Please submit this to the Kansas Department of Insurance 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).


[Exhibit 1 Example: Most recent Audit]
File Named:

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


[Exhibit 2 Example: Asset Sheet showing Surplus vs Liabilities]
File Named:

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


[Exhibit 3 Example: Most Member List with Each Member's Premium]
File Named:

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).


[Exhibit 4 Example: Most Accounting information showing the split]
File Named:

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


[Exhibit 5 Example: Proof of Commissioner approval]

[Exhibit 5 Example: Specific Certificate of Insurance or Policy Declarations Page]
File Named:

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


[Exhibit 6 Example: Certificate of Insurance or Policy Declarations Page for Pool Admin Bond]
File Named:

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).


[Exhibit 7 Example: Banking Statement/Proof of Two Accounts]
File Named:

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).



[Exhibit 9 Example: Certificate of Insurance or Declarations Page for Policy]
File Named:
Agent Named:
NPN:


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

[Exhibit 10 Example: Claims Paid information or Form K-WC-92]
File Named:

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


[Exhibit 11 Example: Most recent Member List]
File Named:

12. Provide the current Indemnity Agreement, underwriting, safety engineering, claims adjusting, or reporting of loss data pursuant to K.S.A. 44-584(a) and 44-582(a)(9-12).


[Exhibit 12 Example: Current Indemnity Agreement, underwriting, safety engineering, claims adjusting, or reporting of loss data]
File Named:

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



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



15. The pool will notify the Commissioner 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 gives notice that the former member has procured workers' compensation and employer's liability insurance elsewhere, whichever occurs first. K.S.A. 44-590(b).



16. 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).


[Exhibit 16 Example: Current Bylaws]
File Named:

17. 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).


[Exhibit 17 Example: Current Trust Agreement]
File Named:

18. The pool will 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).



19. The pool will provide an audited financial statement within 180 days after end of the pool's fiscal year per K.S.A. 44-584(c).


[Exhibit 19 Example: Current Financial Statement/Audit]
File Named:

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



[Exhibit 20 Example: Advisement and approval to the Department letter or email]
File Named:

21. 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 Department of Insurance Financial Surveillance Division.



22. 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 kdoi.rf@ks.gov. 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: