HomeMy WebLinkAbout911168.tiff RESOLUTION
RE: AUTHORIZE SUBMISSION OF APPLICATION FOR SELF-INSURANCE PERMIT FOR WORKERS'
COMPENSATION
WHEREAS, the Board of County Commissioners of Weld County, Colorado,
pursuant to Colorado statute and the Weld County Home Rule Charter, is vested
with the authority of administering the affairs of Weld County, Colorado, and
WHEREAS, upon examination of insurance options for workers' compensation,
it has been recommended by County staff to self-insure beginning January 1, 1992,
and
WHEREAS, in order to self-insure workers' compensation, a Self-Insurance
Permit Application must be submitted to the State Department of Labor and
Employment, Division of Workers' Compensation, and
WHEREAS, the Director of Finance and Administration has prepared said
Application and recommends authorizing the Chairman of the Board of County
Commissioner to sign said Application.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Chairman be, and hereby is, authorized to sign said
Self-Insured Workers' Compensation Application and submit said Application to the
Division of Workers' Compensation.
The above and foregoing Resolution was, on motion duly made and seconded,
adopted by the following vote on the 7th day of October, A.D. , 1991.
//%//JJ BOARD OF COUNTY COMMISSIONERS
ATTEST: ��� �GGG2L �? WELD COUNTY LOR 0
111777 /
Weld County Clerk to the Board
Gor on . acy, a an
By: '7[ it /a/ r' - t����Xi/.q s.-1 G_
Deputy Clerk to the Board---,j eorge Ke edy, Pro-Tem /
APPROVED S-70 FORM: (, a cte-Gv4 L/0-/ o
Constance L. Harbe
County Attorney C. W. Kirby
W. H. Webste
911168
cE :-)N
DIVISION OF WORKERS' COMPENSATION
SELF-INSURANCE PROGRAM
1120 LINCOLN ST. , RM. 1403
DENVER, COLORADO 80203
EMPLOYER'S APPLICATION FOR SELF-INSURANCE
Instructions: Fill in all blanks, write "no" or "none" where
necessary to complete information, and sign and swear to on the
last page. Attach riders where spaces allowed are insufficient.
Name of Employer Weld County, Colorado
Address of Employer 915 10th St. Greeley, CO 80631
The Employer is County Government
(State whether individual, corporation, partnership,
receiver, trustee, etc. )
Incorporated, where and when 1861
The applicant's Federal Employer Identification Number (F.E.I.N. )
84-6000-813
Annual Dividend Rate per share last preceding five years:
19 $ N/A ; 19 $ ; 19 $ ; Note: Not Applicable
19 $ j 19 $ for County Governmen
PRESENT OFFICERS
Office Name Address No. Shares Owned
President * N/A
Vice-President N/A
Secretary N/A
Treasurer Mike Loustalet 915 10th St. Greeley, CO NA
Business engaged in County Government
* County Commissioners:
Gordon Lacy, Chairman 915 10th St. Greeley, CO 80631
George Kennedy
Bill Kirby
Connie Harbert
Bill Webster —1—
0'1.1.?68
How long in such business 130 years
Location of all factories, shops, yards, buildings, premises or
other workplaces of the employer by county, town or city, with
street and number
See attached list
Total number of Colorado employees at date of this statement to be
covered by the proposed Self-Insurance Plan
879
PAYROLL STATEMENT
Project 1992 Wages
No. of
Class No. Manual Classification EmA. Payroll
8831 Animal Shelter 2 $ 26,635
9015 Building Operations 30 544,430
8810 Clerical - Office 374 9,885,981
8832 Clinic & Health Department 23 538,923
9410 Not otherwise classified 71 1,596,945
9101 Library - Other 21 421,491
8868 Library - Professional 27 541,452
7720 Policemen 159 5,082,279
8742 Salesmen - Outside 53 1,072,629
5506 Street & Road 98 2,659,275
7382 Transit Authority 21 255,861
Total: 22,625,901
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Describe briefly the operations pertaining to the warehousing and
transportation of materials, chemicals unfinished or finished
goods.
None
Describe briefly the general character of the operations performed
and the articles manufactured or compounded at the plant or on the
premises of the employer.
County government services: general government, public safety, health, welfare,
road and bridge, education, and employment services.
Describe briefly all classes of work performed away from the
employer's plant or premises, including the demonstration, if any,
of the employer's products and all general operations of
construction, installation or excavation.
Road maintenance and construction, home visits for human services, and police
prorertion.
Describe briefly possible employee exposures to toxic chemicals,
particulate matter which could lead to long term degenerative
diseases, radiation, substances which could create
hypersensitivity, hearing loss or other occupational diseases.
None
No explosives will be made, stored or used on the premises, except
as follows: Sheriff uses ammunition
No corrosive chemicals will be used, except as follows: None
No wrecking or demolition of structures will be done, except as
follows: None
No operations of any nature not herein disclosed will be conducted
by the employer, except as follows: None
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FINANCIAL STATEMENT
Enclose your most recent financial statement and 10 K Report and
those for the preceeding four(4) years.
Attach profit and loss account in detail, for last fiscal year and
the preceeding four(4) years. Enter below the net profit or loss
after taxes for each fiscal year.
YEAR AMOUNT
19 90 $ 11,884,439
19 89 $ 11,762,762
19 88 $ 10,022,891
19 87 $ 6,082,420
19 86 $ 6,677,535
Attach hereto an organizational chart indentifying the hierarchical
position of the applicant as to Parent, Division, or Subsidiary.
List all subsidiaries you wish to self-insure in the State of
Colorado.
None
At the date of application is there any litigation or proceeding
pending or threatened, the result of which substantially adversely
affect the financial condition, business or operations of the
applicant or any of his subsidiaries?
If the answer to the above is "yes" please explain below:
None
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INSURANCE AND LOSS HISTORY
Complete the following relative to the applicant's Colorado
Workers ' Compensation policies.
Name of current carrier County Workers Compensation Pool
(General Re-insurance Corp)
Current policy termination date 12/31/91
Ratio Incurred
Experience Incurred Earned Loss to
Year Payroll Modification Loss Premium Earned Premium
1991 $21,708,558 Pool $ 84,161 $351,003 .23
1990 20,664,308 Pool 99,685 338,003 .29
1989 20,259,430 Pool 383,709 228,553 1.68
1988 19,068,001 Pool 55, 166 198,721 ,28
1987 17,979,599 Self-ins 103,582 N/A N/A
1986 16,927,197 Self-ins 117,466 N/A N/A
Has an application for Worker's Compensation Insurance ever been
retracted or a policy cancelled?
Yes
No X
If yes
On what date --
Why? --
Name of Carrier --
Individual (job title or position) in your organization who will be
responsible for the administration of your Self-Insurance Program.
Donald Warden, Director Finance & Administration Phone # (303 ) 356-4000 Ext 4218
Name and address of the individual or organization, domiciled in
Colorado, responsible for and with authority to admit or deny
liability and pay claims.
Occupational Healthcare Management Services
700 Broadway, Suite 1132
Denver, Co 80273
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If self-insurance permit is granted, the undersigned applicant, in
consideration thereof, agrees as follows:
1. To abide by all the orders, rules and awards of the
Executive Director of Labor and Employment concerning or
against the applicant, unless and until modified by the
Director or as provided by the Workers ' Compensation Act
of Colorado.
2 . To promptly establish reserves as may be requested by the
Director and hereby specifically further agrees that in
case of the cancellation or other termination of his
Self-Insurance Permit, if granted, that any security
deposited by applicant as required by the Director shall
remain deposited after such cancellation or expiration
for such period of time as the Director may deem
advisable for protecting any claims that have been filed
or that may be filed.
Dated Greeley, Colorado this 7th day of
(City and State)
October 19 91
BOARD OF COUNTY COMMISSIONERS
(Employer) WELD 0 TY. COLORADO
i
By /f G
I/ Go don cy, Chairman
+ 41gaiii? Board of ounty Commissioners
Attest: C yygi*,�
Weld County Clerk tto///the Board
BY:4:zeoz,-(712:-iii----1,41,- -freputy
(Affix corporate seal)
The officers signing the above application must attach hereto
certified copy of the resolution of said company authorizing such
officers to make and execute this application on behalf of said
applicant.
If the person signing this application signs in a
representative capacity, a certified copy of the order of Court
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authorizing the execution of this application and the execution of
such surety bonds and self-insurers reserve trust agreements as may
be required by the Director must be attached hereto.
State of Colorado
Weld ' County
Donald D. Warden, Clerk to the Board , being first-duly sworn on
oath deposes and says:
That he is an officer, to-wit: Gordon Lacy, Chairman
of the corporation named as employer in the foregoing application;
that he is acquainted with the affairs of such employer to which he
representations and statements set forth in said application
relate; that he has read said application, knows the contents
thereof and that said representations and statements . therein
contained are true to the best of is knowledge -and bellied; that he
is duly authorized by said compa y to sign e e t pres t said
application.
n �
Subscribed and sworn to before me this 7th day of October
19 91
-4-A7-72 --/-4
Notary Public �—
In and for Weld County
and Colorado State.
Seal MY COMMISSION EXPIRES JUNE 8. 1994
My commission expires
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