(a) Any employer may apply to become an authorized self-insurer. The
application must be addressed to the Branch of Financial Management and
Insurance (Branch) within OWCP's Division of Longshore and Harbor
Workers' Compensation, and be made on a form provided by OWCP. The
application must contain--
(1) A statement of the employer's total payroll for the 12 months
before the application date;
(2) A statement of the average number of employees engaged in
employment within the purview of the LHWCA or any of its extensions for
the 12 months before the application date;
(3) 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 the 5 years before the application date;
(4) A certified financial report for each of the three years before
the application date;
(5) A description of the facilities maintained or the arrangements
made for the medical and hospital care of injured employees;
(6) A statement describing the provisions and maximum amount of any
excess or catastrophic insurance; and
(7) Any other information the Branch requests to enable it to give
the application adequate consideration including, but not limited to,
the reports set forth at Sec. 703.310.
(b) The employer must sign and swear to the application. If the
employer is not an individual, the employer's duly authorized officer
must sign and swear to the application and list his or her official
designation. If the employer is a corporation, the officer must also
affix the corporate seal.
(c) At any time after filing an application, the employer must
inform the Branch immediately of any material changes that may have
rendered its application incomplete, inaccurate or misleading.
(d) By filing an application, the employer consents to be bound by
and to comply with the regulations and requirements in this part.
