Sec. 508.3. Applications

A carrier seeking authority to become a self-insurer must file a verified application which shall include:

(a) the name and address of the principal office of the carrier. If different, the mailing address of the carrier;

(b) a balance sheet prepared within six months of the date of the application giving detailed information concerning the financial condition of the carrier;

(c) an income statement covering at least a 12-month period immediately prior to the date of the filing of the application;

(d) a record of all personal injury or property damage claims, paid and unpaid, filed in the three-year period immediately prior to the date of the filing of the application;

(e) a record of all cargo claims paid and unpaid filed in the three-year period immediately prior to the date of the filing of the application, if applicable;

(f) a list of every insurance policy cancelled within five years prior to the date of the application with a complete explanation as to the circumstances surrounding each cancellation;

(g) the number and description of the vehicles owned or operated by the carrier;

(h) the amount and type of coverage sought to be retained by the self-insurer;

(i) an explanation of procedures to be used for settling or resolving claims, including the name, address and telephone number of the individual designated to receive claims; and

(j) a copy of a Federal Motor Carrier Safety Administration order granting permission to become a self-insurer, plus the documentary evidence upon which the order was based, if available.