Application for certificate of self-insurance
Source version current through Mar 15, 2023
Later State Register activity may affect this section.
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The application for a certificate of self-insurance shall contain:
(a)The following information concerning the applicant:
(1)name of the applicant;
(2)Federal employer's number;
(3)coverage for which self-insurance is requested:
(i)property damage;
(ii)bodily injury;
(4)amount of reserves set aside to meet future claims;
(5)manner in which claims are investigated and adjusted;
(6)number of accidents in last two years;
(7)number of claims and amounts;
(8)number of settlements and amounts;
(9)number of judgments open and unsatisfied; and
(10)period of time covered by certificate of self-insurance.
(b)The following information concerning each snowmobile to be covered by self-insurance:
(1)year of manufacture;
(2)make of snowmobile;
(3)identification number; and
(4)registration number.
(c)An affidavit attesting to the truth of the above information, signed by the chief fiscal officer of the applicant and acknowledged by a notary public.