Current through Register Vol. 46, No. 15, April 8, 2022
Certification by the Trustees
a) Each pool must certify its compliance with
Section 107a.08(a) and (b) of the Illinois Insurance Code [215
ILCS 5/107a.08(a) and (b) ] to the
Director by having each pool trustee file the prescribed certification form
below by March 1 of each year to indicate that the pool members possess
homogeneous risk characteristics. The Director may require certifications more
frequently than on an annual basis if deemed necessary.
b) The Trustees shall each certify that:
1) The trustee has requested the
administrator to provide all relevant information regarding the homogeneous
risk characteristics of the members.
2) The trustee has reviewed all relevant
information regarding the homogeneous risk characteristics of the members as
well as the guidelines relating to homogeneity in Section 107a.08 of the Code,
in addition to those defined in Section
575.110 of this
Part.
3) Based on the trustee's
knowledge and review, the trustee shall verify that the certification is true,
complete and not misleading.
4)
Based on the trustee's knowledge, the certification presents in all material
respects that the members exhibit homogeneous risk characteristics under the
membership scope adopted by the pool.
5) The trustee understands his or her legal
responsibility to ensure under Article V3/4 of the Code that the members
exhibit homogeneous risk characteristics.
c) The certification must be accompanied by a
list of members as of the end of the previous year that includes for each
member a description of business activities, list of NCCI class codes used to
classify the member's payroll, gross annual payroll by class code, number of
employees, and identification of new members added during the previous
year.
d) For the initial
certification, March 1, 2010, an affidavit describing the membership scope of
the pool consistent with the standards prescribed in this Part must accompany
the certification. Supporting documentation must be submitted that demonstrates
that the membership scope possesses homogeneous risk characteristics.
STATE OF ILLINOIS
CERTIFICATION OF HOMOGENEITY
I, __________(Name of Trustee)__________ , a Trustee or
Director of ________________(Name of Workers' Compensation Pool)____________
present this Certification to the Director of Insurance of the State of
Illinois for the period of January 1 through December 31, _______________. I
certify that:
(1) I have requested the
administrator provide all relevant information regarding the homogeneous risk
characteristics of the members.
(2)
I have reviewed all relevant information regarding the homogeneous risk
characteristics of the members, as well as the guidelines relating to
homogeneity in Section 107a.08 of the Illinois Insurance Code [
215
ILCS 5/107a.08 ] and 50 Ill. Adm. Code
575.
(3) Based on my knowledge and review of (2)
above, I verify that the certification is true, complete and not
misleading.
(4) I understand the
legal responsibility I have in respect to ensuring that the members exhibit
homogeneous risk characteristics.
(5) I certify that the members do exhibit or
do not exhibit (Please check one)homogeneous risk characteristics relative to
the membership scope adopted by the pool.
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Signature
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Title
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Printed Name
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Date
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Street Address
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City
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State
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ZIP Code
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Notary Public
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__________________
(Seal)
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Date
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