Welcome to Builders Trust of New Mexico s WebTropics Online Application Processing System

Transcription

1 Welcome to Builders Trust of New Mexico s WebTropics Online Application Processing System Subject: Online Instructions for New Participant Applications Dear Agent, If you are new to this online application process, please be sure to read this document thoroughly. It is your responsibility to make certain that the necessary New Participant paperwork is submitted accurately and within a timely manner (no later than 15 days past the online submission date) to our Marketing General Agent s office Ronnie Letcher MGA, LLC in Artesia, NM. As part of the application process, and in keeping with the Group Self Insurance Act requirements (Article 6, Chapter 52, 6-1 through 25), it is necessary for you to complete the following online form in its entirety to ensure Fund requirements are met. Please note that each document must bear the owner s original signature in order to be considered valid before coverage can be bound. WebTropics Paperwork to Print Application for Membership Indemnity Agreement Premium Computation Financial Statement (six months old/earlier) Corporate Resolution (if applicable) Corporate Officer Exemption (if applicable) Sole Proprietor/Partner Election/Rejection (if applicable) New Participant Supplement Uninsured Subcontractor New Participant Orientation Certificate of Authorization for LLC Additional Paperwork Required Copy of Proof of Home Builders Association (HBA) Membership Local HBA Offices: Copy of NCCI Experience Modification (e-mod) Worksheet (if applicable) Rating Organization: Copy of Prior Carrier Loss Runs, Past 3 Years (if applicable) Submit complete packet, including the applicant s deposit payment (25% of estimated premium) to: Builders Trust of New Mexico c/o Ronnie Letcher MGA, LLC PO Box 542 Artesia, NM If you have any questions regarding this process, please contact:

2 Ronnie Letcher, MGA or Peggy Miller-Letcher, CISR Ronnie Letcher MGA, LLC Phone: (575) or (888) Fax: (575) Thank you for supporting Builders Trust of New Mexico new business efforts. Best Regards, Underwriting Department Builders Trust of New Mexico

3 Participant Application Name Address STREET CITY STATE ZIP We hereby formally apply for participation for self-insurance coverage in Builders Trust of New Mexico, affiliated with New Mexico Home Builders Association ( Group ), to be effective 12:01 a.m. And if approved for participation in the Group by its duly authorized representative, do hereby constitute and appoint Builders Trust of New Mexico to act as agent in-fact in all matters relating to the New Mexico Group Self- Insurance Act. We further agree as follows: a) To accept and be bound by all provisions of the New Mexico Group Self-Insurance Act and all regulations promulgated thereunder or otherwise applicable to the Group including provisions allowing for necessary rate adjustments as determined by Builders Trust. b) That, by this reference, the terms and provisions of the Indemnity Agreement and/or Amendments thereto filed or which may hereafter be filed with the State of New Mexico Workers Compensation Administration by the Group are hereby adopted, approved, ratified and confirmed by us; and further, we agree to assume all of the obligations set forth therein, including our joint and several liabilities for payment of any lawful awards against any participant of the Group; and in the event we fail to pay any premium or lawful assessment within thirty (30) days of the date the same shall become due, we will pay all costs of the collection thereof, including reasonable attorney s fees and expenses, and interest on all unpaid amounts at the lesser of the rate of 18% per annum or the maximum lawful rate. c) To abide by the Articles of Association, the Bylaws and policies, rules and regulations of the Group established from time to time by the Board of Trustees of the Group, and to conform to the terms of the agreements the Group may enter into from time to time with any authorized service organization so long as we remain a participant of the Group. d) To insure that my membership with the New Mexico Home Builders Association (NMHBA) does not lapse while I have coverage in force. I further authorize Builders Trust of New Mexico to pay, in advance on my behalf, all fees associated with my membership in my local association, NMHBA and National Association of Home Builders and furthermore reimburse Builders Trust for said fees during the membership coverage period which will be prorated and collected during the normal monthly premium reporting period. Any unreimbursed fees will be due in full and collected at time of termination of coverage and right of offset may be used for any amount unpaid from any deposits being held. See Policy for further details. e) To abide by the laws and rules of New Mexico and Construction Industries Division as regards contractor licensing to the extent applicable. f) That we agree to notify the Group immediately in the event that any locations are to be added or deleted from the coverage, and in the event of a company name change, the formation of a new entity (such as a corporation or partnership), the sale or transfer of an ownership interest in the company, the sale or transfer of substantially all of the company assets, a combination, merger or consolidation of companies or entities, or the establishment of a trustee or receiver with respect to the company (other than a debtor in possession or trustee under a revocable trust or franchisor), and we understand that the Group reserves the right to deny coverage in the event that we fail to comply with the foregoing. We agree that the acceptance by the Group of a check drawn on an account in a name other than the Participant identified in this application will not constitute a waiver of any right of the Group with respect to coverage or other issues that may arise. g) That should we desire to cancel our coverage, we will give written notice by certified mail at least thirty (30) days prior to cancellation, and that the Group will give written notice by certified mail at least thirty (30) days prior to cancellation, should the Group desire to cancel our coverage for reasons other than nonpayment of premiums or violations of the Articles of Association, the Bylaws of the Group or policies, rules and regulations. h) That the Group shall have the right, in the course of the business of the Group, to disclose to our agent of record information obtained or developed in connection with our account, including but not limited to information obtained through the Confidential Request for Information and information obtained through any audit of our company by the Group. i) That the receipt, endorsement and/or deposit by the Group of any check delivered by us shall not constitute a waiver of any right of the Group, including but not limited to the right to cancel coverage if such right existed prior to such receipt, endorsement and/or deposit, and that the Group may retain any amounts so received until a final audit of our account has been completed, and that the Group may apply any amounts so received toward any amount we owe to the Group. j) That a signed copy of this Participant Application received by telefacsimile or other electronic means shall be deemed to be a counterpart original, and shall have the same force and effect for all purposes as the original document bearing the original signature or signatures. Printed name of applicant/title Signature of applicant Date Agent company Agent name The above applicant is hereby approved for participation in the Group, and coverage is effective the day of, 20. Signed the day of, 20. Builders Trust of New Mexico by Group Administrator

4 Indemnity Agreement The purpose of this Indemnity Agreement is to affirm the joint and several obligations of members of the New Mexico Home Builders Association Builders Trust of New Mexico ( Group ), and to make any and all payments which maybe necessary to meet the Group s obligations under the New Mexico Group Self-Insurance Act. to this end, the undersigned agree (s) as follows: Because the amount required to fulfill workers compensation obligations cannot be known precisely in advance, assessments, reserve requirements and other financial parameters of the Group s operation must necessarily be initially established and subsequently maintained by means of estimates. Any interim transactions and their effects on the Group notwithstanding, it is mutually agreed by the Group and each of its members that all members participating in the Group for any period of time will be jointly and severally liable for payment of any assessments, premiums, and other amounts necessary to meet any benefit, expense or other lawful obligation of the Group arising from that period of time. This joint and several liability will apply without limitations as to the amount, and without any restriction as to when any portion of the obligation is identified. Specifically, any members who terminate their participation in the Group, voluntarily or involuntarily, will remain jointly and severally liable for payment of any Group obligations attributable to their period membership, regardless of when part or all of those obligations became known. DATED, 20 GROUP MEMBER BY TITLE BUILDERS TRUST OF NEW MEXICO BY ADMINISTRATOR all rights reserved, doc. revised 11/28/06

5 Premium Computation Sheet NAME HBA INFORMATION MAILING ADDRESS PHYSICAL ADDRESS HBA CHAPTER HBA NUMBER EXPIRATION DATE TELEPHONE FAX (CPA/ACCOUNTANT NAME, MAILING ADDRESS AND TELEPHONE/FAX FOR PAYROLL RECORDS) Federal Tax ID# License # Classification NM Unemployment ID# Contractors License # # of Employees Please select: Individual Partnership Corporation Other We hereby apply for participation in the Group effective at 12:01a.m.,. CODE DESCRIPTION ESTIMATED PAYROLL RATE PER $100 ESTIMATED PREMIUM TOTAL DOLLARS PLEASE NOTE: The New Mexico Group Self Insurance Act allows for necessary rate adjustments as determined by the Builders Trust Board of Trustees and approved by the Workers Compensation Administration. (1) Plus Tier Level... $ ( ) Subtotal... $ (2) Experience Modifier... Modified Premium...$ (3) Less Stock Discount (if applicable) % ( ) Subtotal..... (4) ESTIMATED ANNUAL PREMIUM...$ (5) Premium Deposit Due (25% of Estimated Annual Premium) $ (6) Total Deposit...$ all rights reserved, doc. revised 11/28/06

6 Financial Statement Current Assets (receivable in 1 year or less) Cash in Bank or in hand...$ Amount due on completed contracts....$ Materials (Cost)...$ Receivables due (Short Term)...$ Note Receivable Itemize TOTAL $ Itemize TOTAL CURRENT ASSETS $ FIXED ASSETS Equipment & Tools (Depreciated Value)...$ Notes Receivable (Long Term) Itemize TOTAL $ Real Estate & Building (Depreciated Value)... Description Other Assets Itemize TOTAL $ TOTAL FIXED ASSETS $ TOTAL ASSETS $ Current Liabilities Accounts Payable For Materials...$ To Others...$ Notes Payable (Long Term) Itemize TOTAL $ TOTAL CURRENT LIABILITIES $ FIXED LIABILITIES Mortgages on Real Estate...$ Notes Payable (Long Term) Itemize TOTAL $ TOTAL FIXED LIABILITIES $ TOTAL LIABILITIES $ Net Working Capital (Difference between Current Assets & Current Liabilities)...$ Net Worth (Difference between Total Assets & Total Liabilities)...$ Name (Company Official Signature) Date Company Name I,, do solemnly swear that all statements on the Applicaton are true and correct. all rights reserved, doc. revised 11/28/06

7 STATE OF NEW MEXICO WORKERS COMPENSATION ADMINISTRATION NEW MEXICO SOLE PROPRIETOR AFFIRMATIVE ELECTION FORM PLEASE TYPE OR LEGIBLY PRINT ALL ENTRIES EXCEPT SIGNATURE I, am a self-employed person. My (Name of sole proprietor) business(es), located at (Business name(s), Attach separate sheet if necessary) (Physical address) is a (are) sole proprietorship(s) subject to the provisions of the New Mexico Workers Compensation Act (The Act). Pursuant to of the Act, I AFFIRMATIVELY ELECT NOT TO ACCEPT THE PROVISIONS OF THE WORKERS COMPENSATION ACT FOR MYSELF ONLY. I meet the qualifications of , as related to sole proprietors as follows: I own all the assets of the business(es). I am solely liable for the debts of the above named sole proprietorship(s). In consideration for exclusion of myself from workers compensation insurance premium computations and coverage I agree to, and understand the following: I understand that this election may not exclude me from the employee headcount for purposes of determining the insurance coverage requirements of the Workers Compensation Act. I understand that if I employ 3 or more workers total, in all my businesses, family members, relatives, friends or part time workers, and possibly myself, I must buy workers compensation insurance to provide coverage for all of those workers. I understand that if my business(es) is(are) subject to the licensing requirements of the Construction Industries Act, I am required to buy insurance even if I am the only worker in the business. I understand that this election applies only to myself as a worker in my business(es). All other workers are subject to the coverage requirements of The Act and are subject to the workers compensation assessment fee. I understand that if required by The Act, this election does not excuse me from having workers compensation insurance coverage for my employees. I acknowledge that this election excludes only myself from coverage and not any of my other workers. I understand that if I employ any other worker in my business even temporarily, I will not be eligible for a minimum premium policy and may owe increased premium payments. I understand that if I wish to revoke this election, the revocation must be made pursuant to section of The Act. I understand that I may not make a claim for myself on any workers compensation insurance policy for any business(es) owned by me, for any work related injury or illness occurring to me while this election is in effect. I have been advised that I or my health insurance provider will be fully responsible for my medical costs from such an injury or illness since I am electing not to be covered by worker s compensation insurance. Page 1 of 2 rev. 11/28/06

8 I understand that by accepting this Affirmative Election, it applies to all sole proprietorships I own. I further understand that if I wish to revoke my election, I am required by law to file a revocation with my insurance carrier and with the Workers Compensation Administration. I further agree to notify the Workers Compensation Administration of any changes in my status. I swear or affirm under penalty of perjury that: I have read the foregoing New Mexico Sole Proprietor Affirmative Election Form in its entirety and, I understand the information contained therein and, that it is true and correct to the best of my knowledge. Signature: Title: FEIN Number CRS# (Mailing Address) STATE OF COUNTY OF Sworn and subscribed before my this date: My commission expires: Notary Public INSTRUCTIONS AND EXPLANATION 1) Please notify this office if change in sole proprietor and/or employment status occurs. 2) Return the completed and notarized form to your insurance carrier who will then forward this form to: New Mexico Workers Compensation Administration Attn: Employer Compliance Bureau P.O. Box Albuquerque, NM ) Please call the New Mexico Workers Compensation Administration at (505) or at for questions or clarifications. Page 2 of 2 doc. revised 11/28/06

9 EMPLOYERS ELECTION TO ACCEPT THE PROVISIONS OF THE NEW MEXICO WORKERS COMPENSATION AND OCCUPATIONAL DISEASE DISABLEMENT ACTS EXEMPTION ACTIVE CORPORATE OFFICER WITH 10% OR MORE OF CORPORATE STOCK ELECTION NOT TO ACCEPT PROVISIONS OF THE NEW MEXICO WORKERS COMPENSATION AND OCCUPATIONAL DISEASE DISABLEMENT LAW I,, do hereby certify that I own 10% or more of the outstanding stock of, who is an employer pursuant to Sections and NMSA Full knowledge is present in making the ELECTION NOT TO ACCEPT PROVISIONS OF THE NEW MEXICO WORKERS COMPENSATION ACT AND OCCUPATIONAL DISEASE DISABLEMENT LAW, and the following stated conditions exist. A) Corporate Officer status can be verified and, B) Corporate Officer is employed by corporation and, C) Corporate Officer fully understands that this rejection includes any other NM Corporation(s) in which he or she has a financial interest and, D) Corporate Officer agrees to notify the Director s Officer of any changes in the above. Unemployment ID Number (SIGNATURE) (TITLE) (DATE) EXEMPTION ACTIVE CORPORATE OFFICER WITH 10% OR MORE OF CORPORATE STOCK ELECTION NOT TO ACCEPT PROVISIONS OF THE NEW MEXICO WORKERS COMPENSATION AND OCCUPATIONAL DISEASE DISABLEMENT LAW I,, do hereby certify that I own 10% or more of the outstanding stock of, who is an employer pursuant to Sections and NMSA Full knowledge is present in making the ELECTION NOT TO ACCEPT PROVISIONS OF THE NEW MEXICO WORKERS COMPENSATION ACT AND OCCUPATIONAL DISEASE DISABLEMENT LAW, and the following stated conditions exist. A) Corporate Officer status can be verified and, B) Corporate Officer is employed by corporation and, C) Corporate Officer fully understands that this rejection includes any other NM Corporation(s) in which he or she has a financial interest and, D) Corporate Officer agrees to notify the Director s Officer of any changes in the above. Unemployment ID Number (SIGNATURE) (TITLE) (DATE) This election NOT to be subject to said sections of the New Mexico Law will remain in effect until such time that revocation of this filing is made in the office of Builders Trust. 1

10 Special Meeting of the Board of Directors Builders Trust of New Mexico Now on the day of, 20. The Board of Directors of the Corporation met at the Company Office in, New Mexico, all Members of the Board being present and in person. The meeting was called to order by the President who asked that the purpose of the meeting be a discussion as to whether or not the Corporation will join in an Association for the purpose of pooling Workers Compensation Coverage. After full discussion and after motions having been made and seconded, the following Resolution was unanimously adopted. BE IT RESOLVED that the appropriate Officers are hereby authorized and directed, to make, execute, and deliver to Builders Trust of New Mexico, an unincorporated Association, an application for Membership, including indemnity agreement, attorney-in-fact, Application, and such other guarantees or documents as required for membership. CORPORATION SECRETARY PRESIDENT There being no further business to come before this meeting, and upon motion having been duly made and seconded, the meeting was adjourned. all rights reserved, doc. revised 11/28/06

11 New Participant Supplement Producer Name Builders Trust of New Mexico Applicant Name Years in Business Description of Business Operation Location of Operation POLICY INFORMATION Previous Insurer Proposed Effective Date Previous Policy Number Special Company & State Information INDIVIDUALS INCLUDED/EXCLUDED (Partners, Self-employed persons, and Executive Officers of a Corporation who own at least 10% of the stock of the corporation may accept or reject coverage under the Workers Compensation Act.) Remuneration to be included must be a part of the Premium Computation Sheet. OWNERSHIP INC/ CLASS ACTUAL ANNUAL NAME TITLE PERCENTAGE DUTIES EXCL CODE PAYROLL PRIOR COVERAGE (Provide information for past 3 years and include LOSS RUNS) YEAR CARRIER POLICY NUMBER MODIFIER PREMIUM GENERAL INFORMATION Please provide all the required details for YES responses on the back of this form or an attachment. YES NO 1. Does the applicant own or lease aircraft? 2. Do covered employees fly in company owned, operated, or leased aircraft? If YES, complete aircraft supplement 3. Any exposure to flammables, explosives, caustic fumes or asbestos other than normal or customary in the construction table? 4. Any work performed underground or above 3 stories? 5. Is applicant engaged in any other type of business? 6. Are any subcontractors used? 7. Any work sublet without Certificates of Insurance? 8. Is a formal safety program in operation? 9. Any employees under 18 years of age? 10. Any part time or seasonal employees? 11. Is there any volunteer or donated labor? 12. Do employees travel out of state? 13. Are athletic teams sponsored? Do company employees participate in company sponsored teams (ie. bowling, softball)? 14. Is information required regarding preexisting medical conditions and prior workers compensation claims after a conditional job offer has been made? 15. Is a physical exam required after a conditional job offer has been made? 16. Have you previously been insured by Builders Trust of New Mexico? AGENT SECTION (Please confirm and secure documents as requested) 1. Did Agent explain New Participant Orientation requirement? 2. Did Agent explain the Uninsured Subcontractor requirements? 3. Has the Agent reviewed payroll reporting, late pay, and cancellation policies and procedures? 4. Is a copy of your most recently filed Quarterly Federal Tax Return, Form 941 attached? 5. Is a copy of your most current financial statement attached (not more than six months old)? SAFETY INSPECTION CONTACT NAME/ PHONE NUMBER APPLICANT'S SIGNATURE PRODUCER S SIGNATURE DATE all rights reserved, doc. revised 11/28/06

12 Subcontractor Requirements Subcontractors working on the job sites of Builders Trust Participants are required to furnish a Certificate of Insurance for workers compensation insurance coverage to the Participant. Participants must keep current certificates of insurance on file for all subcontractors. These certificates should be kept on file at least until the Builders Trust Premium Auditor has completed the annual audit of your payroll records. Premium charges will be incurred for all uninsured subcontractors. Payments to uninsured subcontractors and their employees must be reported, and premium paid, on the monthly payroll reports submitted to Builders Trust. If the code in which the subcontractor works is pre-printed on the payroll reports, we require that the subcontractor be listed separately from a Participant s own payroll or noted that the payroll amount is for an uninsured subcontractor. If the code is not pre-printed on the payroll reports, we require that Participants contact the Builders Trust office to obtain authorization prior to using a classification code. Workers Compensation Premium is charged on uninsured subcontractors as follows: 1.) 100% of all bills which do not show a breakdown of labor and materials. 2.) 100% of labor on bills showing a breakdown of labor and materials. 3.) 100% of all casual labor. An uninsured subcontractor is any contractor who does not provide a Participant with a valid and current Certificate of Insurance showing that the subcontractor has workers compensation insurance coverage. It is strongly recommended that you do not use uninsured subcontractors. Uninsured subcontractors represent extensive liabilities from which your workers compensation insurance may not protect you. These liabilities far outweigh any savings you may receive by using uninsured subcontractors. Current New Mexico law requires all employers in the construction industry that are required to be licensed by the Construction Industries Division, and who have one or more employees, carry workers compensation insurance. NOTE: Even though the law may allow certain individuals to exempt themselves from carrying workers compensation coverage, Builders Trust requires all subcontractors and casual labor to furnish certificates of workers compensation insurance coverage. Builders Trust Participants will be charged for them as outlined. I hereby acknowledge, have read, and understand the information in this document. My agent explained and I further understand that it is my sole responsibility to inform my accountant and/or person responsible for maintaining my monthly payroll reports of this requirement. PARTICIPANT Date AGENT Date all rights reserved, doc. revised 11/28/06

13 New Participant Orientation Acknowledgement I acknowledge that attendance at a New Participant Orientation within 90 days of joining Builders Trust is a requirement of continuing participation in the fund. Nonattendance within 90 days or after three (3) invitations, whichever comes first, can be cause for cancellation. Either myself or a designated representative will attend the New Participant Orientation (NPO) in accordance with the conditions stated above. Signature Date Was Participant previously insured by Builders Trust of New Mexico? Yes No If yes, please indicate the approximate date(s) insured. Does Participant presently own or have interest in other companies presently insured by Builders Trust? Yes No If yes, please list name of company(s) and owner interest % % all rights reserved, doc. revised 11/28/06

14 Certificate of Authorization for Limited Liability Company (LLC) Now on the day of, 20. The undersigned hereby certifies to Builders Trust of New Mexico Affiliated with New Mexico Homebuilders Association that all necessary limited liability company action has been taken to authorize the limited liability company identified below to become a Participant in Builders Trust of New Mexico Affiliated with New Mexico Homebuilders Association for the purpose of pooling Workers Compensation Coverage and becoming a member of a self-insured group, and that the individual signing below in behalf of the limited liability company is authorized to make, execute, and deliver to Builders Trust of New Mexico Affiliated with New Mexico Homebuilders Association an application for Membership, including indemnity agreement, attorney-infact, Application, and such other guarantees or documents as required for membership, on behalf of the limited liability company. NAME OF LIMITED LIABILITY COMPANY: SIGNATURE OF AUTHORIZED INDIVIDUAL PRINTED NAME OF AUTHORIZED INDIVIDUAL TITLE OF AUTHORIZED INDIVIDUAL (MEMBER OR MANAGER)

15 all rights reserved, doc. revised 4/20/04