69O-187.004. Application for the Self-Insurance Trust Fund

(1) Application for the purpose of establishing a self-insurance trust fund shall be made to the Office at Tallahassee. Such application shall contain all information necessary for the Office’s consideration. At the Office’s request, further information or verification as may be reasonably required shall be furnished.

(2) The application shall be made on Form OIR-370 entitled “Application for Approval as a Medical Malpractice Self-Insurance Trust Fund”. The application shall be accompanied by:

(a) A copy of the mutual covenants properly executed pursuant to Rule 69O-187.0081, F.A.C., which binds each member of the Fund to individual, several and proportionate liability as set forth in Section 627.357(7), Florida Statutes.

(b) A copy of the application form for applying for membership in the Fund. THE FORM SHALL CLEARLY STATE IN BOLD PRINT THAT MEMBERS OF THE FUND ARE SUBJECT TO ASSESSMENTS FOR ANY DEFICITS WHICH MAY OCCUR IN THE FUND.

(c) A copy of the Fund’s current financial statement, financial projections, plan of operation, commitments for funds or any other data showing evidence of the financial ability of the Fund to meet its obligations as a self-insurance trust fund. Financial projections of the Fund shall show evidence of the financial ability of the Fund to meet its claims and obligations promptly for a three year period.

(d) A copy of the Service Agent’s contract effective upon the inception date of the Fund. The contract must clearly show all fees to be paid to the Service Agent. Fees must be reasonable in consideration of the duties performed.

(e) A copy of the risk management program required pursuant to subsection 69O-187.005(6), F.A.C.

(f) Biographical statements completed on the form entitled “Biographical Statement” as contained within the Application (Form OIR-370), and fingerprint cards for each individual to be participating in the management of the Fund unless submitted pursuant to subsection 69O-187.003(6), F.A.C.

(g) A copy of all marketing material that the Fund intends for general distribution to prospective members. All such marketing material shall clearly state in bold print that members of the Fund are subject to assessments for any deficits which may occur in any Fund year during which the member participated in the Fund. All advertisements shall include a statement that “This is an Assessable Self-Insurance Trust.” The Office shall disapprove any material which contains any inconsistent, ambiguous, or misleading clauses.

(h) A copy of the proposed rating plan, indicating the expense factors associated with the proposed rates, and including any premium discount or surcharge schedule and any experience rating plan. The proposed rating plan shall be accompanied by appropriate actuarial support and justification.

(i) A copy of the proposed underwriting guidelines.

(j) A copy of the fidelity bond required by subsection 69O-187.005(5), F.A.C.

(k) A copy of any contract, policy, or agreement providing specific excess insurance or aggregate excess insurance to the Fund as may be required as a condition of approval.

(l) The name of the Fund and the location of the Fund’s principal office, which shall be maintained within this state.

(m) A certified copy of the articles of incorporation, and bylaws, if incorporated, certified as true and correct by the Secretary of State, and a copy of the policy.

(n) The articles of incorporation, bylaws, policy, and mutual covenants shall contain a provision prohibiting any distribution of surplus funds except as approved by the Office.

(o) A complete biographical sketch (resume) on each Trustee of the Fund.

(p) A copy of the Fund’s rules and regulations.

(3) In considering the financial ability of the group to pay its claims and obligations promptly the Office will take into consideration contracts, policies or agreements providing specific excess or aggregate excess coverage of the Fund, the numerical size of the group, the projected gross premiums or charges and the initial financial resources of the group.

(4) The Fund shall not solicit members until such time as the material submitted pursuant to subsection 69O-187.003(2), F.A.C., is preliminarily approved by the Office. Prior to the proposed effective date of the Fund, the Fund shall submit to the Office a copy of each application, proof that each of the prospective members has paid a deposit in an amount of not less than ten (10) percent of the estimated annual premium, and if necessary, proof of alternative financing in an amount sufficient to meet adequate financial ability standards. Nothing herein shall prohibit the organizers of a fund from discussing the formation of the Fund with prospective members.

(5) Prior to final approval, the Office shall be notified of and provided copies of all changes in information or documentation previously submitted. Upon becoming satisfied of the financial ability of the Fund to fulfill all of its obligations that might arise, upon being satisfied that the Fund has the facilities and personnel necessary to service the self-insurance trust fund contemplated and upon being satisfied that the Fund has achieved an adequate level of participation, the Office may grant final approval for the operation of the Fund subject to the conditions herein provided. The Office in determining an adequate level of participation shall take into consideration the retention level of the Fund, any specific excess or aggregate excess coverage, anticipated premium volume and any other pertinent information the Fund may provide. As a guideline only, a “4 to 1" ratio of the initial year retained premium volume to the retention level per claim may be used by the Office in determining a minimum adequate level of participation.

Specific Authority 627.357(6), 624.308(1) FS. Law Implemented 624.307(1), 627.357 FS. History–New 10-7-75, Formerly 4-39.03, Amended 5-10-89, Formerly 4-39.003, 4-187.004.