Section 67.06 - Application for Certificate of Approval(1)General Provisions. (a) A proposed workers' compensation self-insurance group shall file with the Commissioner its application for a certificate of approval accompanied by a non-refundable filing fee in the amount of $100.00.(b) The Commissioner shall evaluate the information provided in the application to assure that no gaps in funding exist and that funds necessary to pay workers' compensation benefits shall be available on a timely basis.(c) The Commissioner shall conduct an initial review of each application to determine if it is complete. The Commissioner shall act upon a completed application for a certificate of approval within 90 days.(d) The group shall immediately notify the Commissioner of any change in the information required to be filed by 211 CMR 67.06.(e) All information provided by an applicant during the application process shall be given confidential treatment and shall not be subject to subpoena or made public by the Commissioner or any other person, except by the applicant, without the prior written consent of such applicant, unless the Commissioner, after giving the applicant notice and opportunity to be heard, determines that the public interest would be served by the publication thereof, in which event he or she may publish all or any part thereof in such manner as he or she may consider appropriate. Notwithstanding the foregoing, once an application has been approved by the Commissioner it shall be made available to the public; provided, however, that if a group wishes, it may submit two complete sets of statements, one with all identifying information blacked out or deleted, and the other set complete with all the identifying information, and the group's underwriting guidelines, for inclusion in the financial examination file.(2)Application; Required Filings. (a)General Information: the Application for a Certificate of Approval shall be on a form prescribed by the Commissioner and shall include: 1. the name of the group;2. the address and telephone number of the group's principal office;3. the date of organization of the group;4. the name and address of each member of the group;5. the name, address and date of organization of the industry, trade or professional organization to which all the members of the group belong, or identification of the collective bargaining agreement to which all group members are parties;6. the types of business in which employers in the proposed group are engaged and an explanation of how they are the same or similar;7. a listing of the names and addresses of the initial board of trustees and the name and address of the administrator in accordance with the provisions of 211 CMR 67.07.(b)Additional Documents Required from the Group: 1. a copy of the by-laws of the group;2. a copy of the articles of association, trust agreement, or articles of organization;3. a completed and signed application by the administrator to serve as the administrator of the group, on a form prescribed by the Commissioner;4. a certificate indicating that the Commissioner has been appointed the group's agent for service of legal process as required by 211 CMR 67.03(3);5. a schedule of all projected administrative expenses for the group in dollar amount and as a percentage of the estimated standard premium for the group;6. a composite listing of the estimated standard premium and annual net premium to be developed for each member individually and in total for the group amounting to not less than $250,000. The listing shall include and reflect experience modification factors, All Risk Adjustment Program (ARAP) factors, such other rating plan(s) the Commissioner may approve, and any applicable premium discounts. At least 70% of the members of a group shall be experience rated pursuant to the uniform experience rating plan filed with and approved by the Commissioner;7. a listing of payroll data, by workers' compensation class code, for the combined group and for each member of the group for each of the three preceding years;8. a confirmation of required specific and aggregate excess insurance or reinsurance, by an insurer licensed, approved or otherwise authorized to transact excess insurance or reinsurance in the Commonwealth. Such confirmation shall include a description of the coverages offered, the terms and conditions of the coverages and the expected premium charges for the coverages. The amount and the terms of the specific and aggregate excess insurance or reinsurance shall comply with the requirements of 211 CMR 67.21;9. a copy of the fidelity bond, binder, or commitment letter from the surety relating to the fidelity bond for the administrator, on a form prescribed or approved by the Commissioner, in an amount not less than the administrator's total annual compensation for all the groups it administers or $1,000,000, whichever is less. If the group submits a binder, or commitment letter, it must submit a copy of the actual bond to the Division within 60 days after the group is approved;10. the proposed underwriting guidelines for the group;11. a premium payment plan requiring each member to pay the group not less than 25% of the member's estimated annual net premium not later than the initial day of coverage provided by the group. The premium payment plan of a group containing private employers shall also provide that the balance of each member's annual premium be paid in cash within the first eight months of that fund year in monthly or quarterly installments. A public employer group shall establish a premium payment plan acceptable to the Commissioner;12. a detailed written description of the group's safety and loss prevention program(s);13. a refund and assessment plan for the group;14. an actuarial study displaying adequacy of program funding, including loss reserves, prepared and signed by a qualified actuary. The actuarial study shall show that the group is actuarially fully funded, and shall include any and all data, assumptions and other information used to develop such study;15. a pro forma financial statement for the group's first five years of operation, showing the financial ability of the group to pay the workers' compensation obligations of its members, including any and all assumptions relied upon to develop such statement;16. for a group containing private employers, a statement showing the combined provable net worth of all members applying for coverage on the inception date of the group. Such combined provable net worth shall be the amount that establishes the financial strength and liquidity of the members and shall be at least one million dollars;17. for a group containing private employers, a specimen indemnity agreement jointly and severally binding the members of a group to comply with the provisions of 211 CMR 67.00 which shall be executed by the members upon approval of the group by the Commissioner and prior to the commencement of operations. Such indemnity agreement may be included as a provision of the group's membership or participation or similar agreement which each member of a proposed group shall assent to in writing as a prerequisite to membership in the group; provided that the membership, participation or other similar agreement, clearly discloses, as the first provision and in at least ten point type, the member's obligations under the indemnity agreement, including, at a minimum, the provisions of 211 CMR 67.11(3) through (5).(c)Documents Required of Each Member: for each member of the group, the group shall provide the following: 1. An individual application, including a disclosure form describing the joint and several obligations of the members, a certification that the member has no outstanding workers' compensation obligations, and a description of the group's refund/assessment plan, signed by an officer or other responsible employee of the member, on a form prescribed or approved by the Commissioner;2. A written explanation by any member with an experience modification greater than 1.25 describing the causes of its high experience modification and outlining remedial measures it has taken and will be taking in the future to lower its modification;3. Every member of a group containing private employers shall also submit the following documents: a. a certified or compiled financial statement, subject to the requirements of 211 CMR 67.06(1)(e); this requirement, however, shall not apply to a self-insurance group which is composed of more than 1,000 members and has been in existence for at least five years as of December 31, 1999 and at all times remains in compliance with the minimum net worth requirements of both 211 CMR 67.08(2)(c) and 67.10.b. a written agreement to pay the group not less than 25% of the member's estimated annual net premium not later than the initial day of coverage afforded by the group.Amended by Mass Register Issue 1320, eff. 8/26/2016.