[Code of Federal Regulations]
[Title 20, Volume 3]
[Revised as of April 1, 2003]
From the U.S. Government Printing Office via GPO Access
[CITE: 20CFR703.302]

[Page 913]
 
                      TITLE 20--EMPLOYEES' BENEFITS
 
  CHAPTER VI--EMPLOYMENT STANDARDS ADMINISTRATION, DEPARTMENT OF LABOR
 
PART 703--INSURANCE REGULATIONS--Table of Contents
 
Sec. 703.302  Application for authority to become a self-insurer; how filed; information to be submitted; other requirements.

    Application for authority to become a self-insurer may be made by 
any employer desiring such privilege and shall be addressed to the OWCP 
and be made on a form provided by the Office. Such application shall 
contain:
    (a) A statement of the employer's payroll report for the preceding 
12 months; (b) a statement of the average number of employees engaged in 
employment within the purview of the LHWCA or any of its extensions for 
the preceding 12 months; (c) a statement of the number of injuries to 
such employees resulting in disability of more than 7 days' duration, or 
in death, during each of 3 years next preceding the date of the 
application; (d) a certified financial report for each of the three 
years preceding the application; (e) a description of the facilities 
maintained or the arrangements made for the medical and hospital care of 
injured employees; and (f) a statement describing the provisions and 
maximum amount of any excess or catastrophic insurance. The Office may 
in its discretion require the applicant to submit such further 
information or such evidence as the Office may deem necessary to have in 
order to enable it to give adequate consideration to such application. 
Such application shall be signed by the applicant over his typewritten 
name and if the applicant is not an individual, by an officer of the 
applicant duly authorized to make such application over his typewritten 
name and official designation and shall be sworn to by him. If the 
applicant is a corporation, the corporate seal shall be affixed. The 
application shall be filed with the OWCP national office in Washington, 
DC. The regulations in this part shall be binding upon each applicant 
hereunder and the applicant's consent to be bound by all requirements of 
the said regulations shall be deemed to be included in and a part of the 
application, as fully as though written therein.

(Approved by the Office of Management and Budget under control number 
1215-0160)

(Pub. L. No. 96-511)

[38 FR 26873, Sept. 26, 1973, as amended at 50 FR 406, Jan. 3, 1985]