(a) How filed. Application for authority to become a self-insurer
shall be addressed to the Office and be made
[[Page 80100]]
on a form provided by the Office. Such application shall be signed by
the applicant over his typewritten name and if the applicant is not an
individual, by the principal 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 Office in Washington, D.C.
(b) Information to be submitted. Each application for authority to
self-insure shall contain:
(1) A statement of the employer's payroll report for each of the
preceding 3 years;
(2) A statement of the average number of employees engaged in
employment within the purview of the Act for each of the preceding 3
years;
(3) A list of the mine or mines to be covered by any particular
self-insurance agreement. Each such mine or mines listed shall be
described by name and reference shall be made to the Federal
Identification Number assigned such mine by the Bureau of Mines, U.S.
Department of the Interior;
(4) A certified itemized statement of the gross and net assets and
liabilities of the operator for each of the 3 preceding years in such
manner as prescribed by the Office;
(5) A statement demonstrating the applicant's administrative
capacity to provide or procure adequate servicing for a claim including
both medical and dollar claims; and
(6) In addition to the aforementioned, 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.
(c) Who may file. An application for authorization to self-insure
may be filed by any parent or subsidiary corporation, partner or
partnership, party to a joint venture or joint venture, individual, or
other business entity which may be determined liable for the payment of
black lung benefits under part C of title IV of the Act, regardless of
whether such applicant is directly engaged in the business of mining
coal. However, in each case for which authorization to self-insure is
granted, the agreement and undertaking filed pursuant to Sec. 726.110
and the security deposit shall be respectively filed by and deposited
in the name of the applicant only.
