Application for a Self-Insurer Status

PURPOSE: This rule sets forth the requirements which an application for self-insurer status must meet. (1) Motor carriers operating in intrastate commerce filing an application for authority to become a self-insurer shall file an application with the director of the division. Every application shall include a completed Application for Self-Insurer Status Form, included herein, and whenever applicable shall include completed Exhibits A, B, C, D, and E, as described in the application form. The application may include additional supporting information, which shall not repeat or duplicate the information required in Application for Self-Insurer Status Form or Exhibits A, B, C, D, and E. Photocopies of the form and exhibits are acceptable, if they are clearly legible. (2) Except as provided in section (3) of this rule, each motor carrier who has been granted authority by this division to be a self-insurer shall file, within sixty (60) days after the close of the previous calendar year, a balance sheet, income statement, and a statement listing any claims filed against the motor carrier which arose out of any accidents the motor carrier was involved in during its operations in the previous calendar year, and any unresolved claims which arose out of accidents during previous years. For each claim listed, the applicant shall state the amount, nature, and status of the claim including whether it is disputed or undisputed and how much of it remains unpaid. (3) Any carrier whose self-insurance plan has been approved by the Federal Motor Carrier Safety Administration (FMCSA) shall file with this division— (A) The FMCSA order approving its self-insurance plan; and (B) Immediate notice of any proceeding or action by the FMCSA which could result in the suspension, revocation, or termination of its self-insurance plan. (4) Failure of a carrier to comply with the provisions of section (2) or (3) of this rule shall result in revocation of the commission’s approval of the carrier’s self-insurance plan. TRANSPORTATION Missouri Department of Transportation Motor Carrier Services PO Box 270, 830 MoDOT Drive, Jefferson City, MO 65102-0270 E-mail: contactmcs@modot.mo.gov Phone: 866.831.6277 Fax: 573.522.6708 SELF-INSURER STATUS APPLICATION SECTION 1. REQUEST FOR SELF-INSURER STATUS (Check only one) 1. Applicant requests approval to be a self-insurer for the transportation of property or passengers in intrastate commerce without a self-insurance plan approved by the Federal Motor Carrier Safety Administration (See Section 4 for required attachments). 2. Applicant requests approval to be a self-insurer for the transportation of property or passengers in intrastate commerce pursuant to a self-insurance plan approved by the Federal Motor Carrier Safety Administration (Attach copy of order in effect as Exhibit A). SECTION 2. GENERAL INFORMATION USDOT NO. FMCSA NO. FEIN/SSN (SSN Sole Proprietor Only) LEGAL NAME DOING BUSINESS AS (DBA) NAME PRINCIPAL PLACE OF BUSINESS ADDRESS (not a PO Box) - STREET CITY STATE ZIP CODE MAILING ADDRESS (if different from Principal address) - STREET CITY STATE ZIP CODE MISSOURI TERMINAL ADDRESS (if any) - STREET CITY STATE ZIP CODE PHONE NO. FAX NO. E-MAIL ADDRESS SECTION 3. FORM OF BUSINESS Sole Proprietor Partnership Limited Partnership Limited Liability Partnership Limited Liability Company Corporation Trust STATE OF ORGANIZATION/INCORPORATION DATE ORGANIZED CHARTER NO. NAME OF COMPANY OFFICERS OR PARTNERS PLEASE PRINT SECTION 4. ATTACHMENTS FOR SELF-INSURER STATUS (Required only if #1 checked in Section 1). The applicant has attached the following exhibits as required: Exhibit B - Balance sheet prepared within the last six months prior to the filing of the application giving detailed information concerning the financial condition of the applicant. Exhibit C - Income statement of applicant showing in detail its operating results for the twelve month period immediately prior to the date of the filing of the application. Exhibit D - A record of all accidents, losses and claims filed in the five year period immediately prior to the date of the filing of the application and a complete explanation of the disposition of the claims. Exhibit E - Information concerning the cancelation of any insurance policies issued to the applicant by insurance companies authorized to do business in this state, if such coverage related to applicant's operation as an authorized motor carrier. SECTION 5. REQUIREMENTS OF A SELF-INSURER If MoDOT grants authority to the applicant to be a self-insurer with a self insurance plan approved by the Federal Motor Carrier Safety Administration, applicant agrees to provide immediate notice of any proceeding or action by the Federal Motor Carrier Safety Administration, which could result in or has resulted in the suspension, revocation or termination of its self-insurance plan by the Federal Motor Carrier Safety Administration. If MoDOT grants authority to the applicant to be a self-insurer without a self insurance plan approved by the Federal Motor Carrier Safety Administration, the applicant may be required to place in a separate account a minimum reserve amount based upon the carrier's size, operations and claims history. If MoDOT grants authority to the applicant to be a self-insurer without a self insurance plan approved by the Federal Motor Carrier Safety Administration, the applicant agrees to file annually, within sixty days after the close of the calendar year, a balance sheet and income statement and a statement listing any claims filed against the applicant with arose out of any accidents the applicant was involved in during its operations in the previous calendar year, and any unresolved claims which arose out of such accidents during previous years. For each claim listed, the applicant will state the amount, nature and status of the claim, including whether it is disputed or undisputed, and how much of it remains unpaid. SECTION 6. SIGNATURE (An attorney is not required to sign on behalf of a corporation) Applicant, by signing below, agrees to comply with all federal and state safety laws and regulations before the permit, certificate or carrier registration has been issued and before the applicant commences for-hire motor carrier movements. This applicant by signature on and/or delivery of this application to Motor Carrier Services consents on behalf of itself, its affiliates and other persons or entities under its control to be investigated by MoDOT in relationship to the applicant's safety fitness or insurance coverage. This consent extends to a search for and recovery of all evidence relating to compliance with state, federal and local laws. Under penalty of perjury under the laws of the state of Missouri and the United States of America, applicant certifies that the information on this application or attached hereto is true and correct, is authorized to sign this application on behalf of applicant and that the signature is applicant's own true and correct signature made by self or legal representative and by no other person. MO Bar No. If attorney signed on behalf of applicant, print address Date Applicant Signature Applicant Name Printed AUTHORITY: section 622.027, RSMo 2016.* This rule originally filed as 4 CSR 265-2.068. Emergency rule filed Aug. 1, 1986, effective Aug. 13, 1986, expired Oct. 23, 1986. Original rule filed July 31, 1986, effective Oct. 27, 1986. Emergency rescission filed Oct. 3, 1986, effective Oct. 23, 1986, expired Dec. 11, 1986. Amended: Filed May 2, 1991, effective Nov. 30, 1991. Emergency amendment filed Dec. 1, 1995, effective Dec. 11, 1995, expired Dec. 19, 1995. Emergency amendment filed Dec. 20, 1994, effective Jan. 1, 1995, expired April 30, 1995. Emergency amendment filed April 20, 1995, effective May 1, 1995, expired Aug. 28, 1995. Emergency amendment filed Aug. 18, 1995, effective Aug. 29, 1995, expired Feb. 24, 1995. Amended: Filed Aug. 3, 1995, effective Feb. 25, 1996. Moved to 7 CSR 265-10.035 and amended: Filed May 2, 2013, effective Dec. 30, 2013. Amended: Filed June 3, 2022, effective Jan. 30, 2023. *Original authority: 622.027, RSMo 1985, amended 1993, 1995.