§ 125.3. Application.

 (a)  An applicant shall file an application on a form prescribed by the Bureau. Questions on the application shall be answered thoroughly and completely with the most recent information available. A rider may be attached if more space is necessary. The application shall be signed by the applicant, or if a corporation, an officer of the corporation, and attested to as set forth on the application. Attached riders and applicable forms enclosed with the application shall be verified to in the sworn affidavit requested on the application.

 (b)  Initial applications shall be filed with the Bureau no later than 3 months prior to the requested effective date of self-insurance. Renewal applications shall be filed with the Bureau no later than 2 months prior to the expiration of the current permit.

 (c)  With the application, the applicant shall include:

   (1)  The nonrefundable statutory fee in the amount of $500 for initial applicants or $100 for renewal applicants required by section 305 of the act (77 P. S. §  501), payable to the ‘‘Commonwealth of Pennsylvania.’’ A statutory fee in the amount of $500 for initial applicants or $100 for renewal applicants is required for each affiliate or subsidiary included under a consolidated application under §  125.4 (relating to application for affiliates and subsidiaries).

   (2)  Its Security and Exchange Commission (SEC) Form 10-K for the last complete fiscal year, if applicable. The SEC Form 10-K does not serve as a substitute for the full completion of the application form.

   (3)  Its latest audit report issued by a licensed certified public accountant or accounting firm. The report shall cover the last complete fiscal-year period immediately prior to the date of application. If the most current audited period precedes the application date by more than 6 months, the applicant’s latest SEC Form 10-Q or unaudited interim financial statements shall be submitted. The audit report shall meet the following criteria:

     (i)   It shall include financial statements which are presented in conformance with applicable generally accepted accounting principles as promulgated by the Financial Accounting Standards Board or the Government Accounting Standards Board or with international accounting standards promulgated by the International Accounting Standards Board.

     (ii)   It shall state that the audit meets the reporting requirements defined either in the applicable generally accepted auditing standards promulgated by the AICPA or the applicable generally accepted governmental auditing standards promulgated by the Comptroller General of the United States in ‘‘Government Auditing Standards,’’ referred to as the Yellow Book. An unqualified or qualified opinion shall be stated on the most recent audited financial statements.

   (4)  Audit reports covering the applicant’s second and third most recent complete fiscal-year periods prior to the date of the application, if an initial application. If audit reports covering those periods are not available, financial statements reviewed by a certified public accountant in accordance with standards established by the AICPA covering the second and third most recent complete fiscal year periods will be accepted.

   (5)  A report of the applicant’s paid and incurred workers’ compensation loss experience in this Commonwealth under each of the 3 complete policy years prior to the application, if an initial application. Affiliates’ paid and incurred workers’ compensation loss experience shall be submitted if applicable. The loss information for each policy year shall be valued within 3 months prior to the date of the submission of the application.

   (6)  A report on a form prescribed by the Bureau stating the costs of claims incurred by the applicant by annual periods and projecting its outstanding liability under the act and the Occupational Disease Act, if a renewal application. Applicants are encouraged, but not required, to have their projection of outstanding liability prepared by an actuary.

   (7)  A report on a form prescribed by the Bureau summarizing the existence of the accident and illness prevention program required under section 1001(b) of the act (77 P. S. §  1038.1) and regulations promulgated thereunder, if a renewal applicant.

   (8)  At the direction of the Bureau, an applicant’s annual summaries of occupational injuries and illnesses, OSHA No. 200, if the applicant is required to keep Occupational Safety and Health Administration records.

 (d)  The applicant shall provide additional data and information that the Bureau deems pertinent to its review of the application based on the factors enumerated under §  125.6(a) (relating to decision on application). The applicant shall provide the data and information within the time prescribed by the Bureau, which will be reasonable based on the extent and availability of the data and information required.

 (e)  The Bureau will not begin its review of the application until the application and the required supporting materials as outlined in this section have been submitted.

 (f)  An initial applicant’s requested self-insurance effective date is subject to the approval of the Bureau. An initial applicant which fails to insure its liability pending review of its application will be subject to prosecution under the act and the Occupational Disease Act.

   The provisions of this §  125.3 amended October 23, 1998, effective October 24, 1998, apply to applicants, self-insurers, runoff self-insurers, group self-insurance funds and runoff funds, 28 Pa.B. 5459. Immediately preceding text appears at serial pages (201140) to (201141).

   This section cited in 34 Pa. Code §  125.4 (relating to application for affiliates and subsidiaries); 34 Pa. Code §  125.6 (relating to decision on application); and 34 Pa. Code §  125.7 (relating to permit).