BIAW — R.O.I.I. ® 111 21st Avenue SW Olympia, WA 98501 OR [email protected]SEND Return On Industrial Insurance 2020-2021 Plan Year ENROLLMENT INSTRUCTIONS n Application n Underwriting Questionnaire n ABCs of Claim Management Class Registration n Enrollment Fee $150 (min.) Check payable to: BIAW Member Services COMPLETE & INCLUDE The enrollment fee is 1.5% of your L&I premiums owed between Oct. 1, 2018— Sept. 30, 2019 or $150, whichever is greater. Enrollment fees are pro-rated for quarterly enrollment periods (1.125% for October; .75% for January). PAYMENT n (360) 352-7800 n [email protected]QUESTIONS DEADLINES JULY ENROLLMENT: MAY 15, 2020 OCTOBER ENROLLMENT: AUGUST 28, 2020 JANUARY ENROLLMENT: NOVEMBER 13, 2020
Return On Industrial Insurance2020-2021 Plan Year ENROLLMENT INSTRUCTIONS
nApplicationn Underwriting QuestionnairenABCs of Claim Management Class RegistrationnEnrollment Fee $150 (min.) Check payable to: BIAW Member Services
COMPLETE & INCLUDE
The enrollment fee is 1.5% of your L&I premiums owed between Oct. 1, 2018— Sept. 30, 2019 or $150, whichever is greater. Enrollment fees are pro-rated for quarterly enrollment periods (1.125% for October; .75% for January).
R.O.I.I.® SELECT PARTICIPATION REQUIREMENTSn Have a positive reporting history with L&In Must have a current written safety plann Must complete underwriting questionnaire prior to the start of the plan year and a follow-up questionnaire every three yearsn Must agree to light-duty and kept-on-salary (KOS) requirements (see Form 3b, section 5c and 5d)n Owner must attend the ABCs of Claim Management Class prior to the final L&I deadline for enrollmentn AcurrentmembershipinBIAWthroughanaffiliatedlocalhomebuildersassociationisrequiredtoenrollandreceive
refunds in R.O.I.I.® Select
2020-2021 Enrollment, Adjustment and Refund Timeline
L&I Requirements and accepted risk classifications on reverse side
L&I Adjustments and R.O.I.I.® Select Refunds
R.O.I.I.® SELECT INFORMATIONThe R.O.I.I.® Select plan year consists of twelve calendar months beginning on July 1 and ending on June 30 of the following yearaswellasthethreesubsequentannualadjustments,thefirstofwhichoccursroughlytenmonthsaftertheplanyearhasended.Intotal,aplanyearlastsforty-six(46)monthsfromstarttofinish.Memberparticipantsarerequiredtocontinuepayingtheir regular quarterly premiums directly to the Washington State Department of Labor & Industries (L&I) during the plan year.
InApril2022,L&Iwillcalculatethefirstofthreeretrospectivepremiumadjustments.The2020-2021R.O.I.I.® Select plan year refunds are based on what the group participants (your company and others) pay in Standard Premiums to L&I and Developed Losses that L&I charges the group for claims with a date of injury between July 1, 2020 and June 30, 2021.
If the R.O.I.I.® Select group’s Standard Premiums paid exceed its Developed Losses, L&I returns the excess money to the group sponsor. If Developed Losses exceed Standard Premiums paid, member participants may be assessed additional premiums.
Companies that meet program requirements will be automatically re-enrolled for each consecutive new plan year unless a written cancellation request is sent to BIAW or L&I prior to the start of the next plan year.
R.O.I.I.® Select R.O.I.I.® SelectEnrollment Plan Year
JULY: Jan. - April July 1, 2020 - June 30, 2021 April 2022: 1st L&I April 2023: 2nd L&I April 2024: 3rd L&I OCTOBER: May - Aug. Oct. 1, 2020 - June 30, 2021 Adjustment (1 of 3) Adjustment (2 of 3) Adjustment (3 of 3)JANUARY: Sept. - Nov. Jan. 1, 2021 - June 30, 2021 June 2022: First No refund June 2024: Final
refund distribution for distribution refund distribution forpositive* companies positive* companies
R.O.I.I.® SELECT 2020-2021 PLAN YEAR
R.O.I.I.® SELECT REFUNDS ARE BASED ON A 25% PRO-RATA /75% PERFORMANCE DISTRIBUTION MODEL n FIRST ADJUSTMENT REFUND all of the 25% pro-rata share
NO SECOND ADJUSTMENT REFUNDFINAL ADJUSTMENT REFUND distributes all of the 75% performance share
n Company must be a member of BIAW through a local home builders association at the time of refund distribution in orderto receive a refund
n For questions regarding adjustments or the refund timeline, contact R.O.I.I.® Select Marketing/Admin. Services DirectorJenn Kavanaugh at [email protected] or (360) 352-7800, ext. 123
*Positive companies must have a loss ratio (Developed Losses divided by Standard Premium) below .792 for the plan year to qualify for a refund.
0101 Excavation & Grading N.O.C.0103 Drilling & Geophysical Exploration N.O.C.0104 Dredging N.O.C.0105 Fence Erection N.O.C.0107 Undergrd.Utility Line Const. & Pipe laying N.O.C.0108 Sewer & Septic System Construction0112 Sand & Gravel Production including Dealers0201 Bridge, Bulkhead & Tunnel Construction0202 Pile Driving with Water Hazard0210 Asphalt Paving — Streets & Roads0212 Asphalt Paving N.O.C.0214 Concrete Work — Streets & Roads0217 Concrete Work — Foundations & Sidewalks0219 Guardrails,StreetSigns&TrafficLightsInst.0301 Landscape Construction & Renovation0302 Masonry Construction0303 Plastering, Stuccoing & Lathing: Buildings0306 Plumbing0307 HVACSystems—Installation,Svc.&Repair0308 Lawn Care Maintenance0403 Sign Erection0502 FloorCoveringInstallation0504 Painting: Building & Structures — Ext. Work0506 Building Moving/Wrecking0507 Roof Work — Construction & Repair
Applies to establishments engaged in all aspects of construction-related services and activities as a primary business undertaking. The following risk classifications (and sub classifications) include operations applicable to Construction and Related Services:
0508 Struct. Steel Erec. — Towers, Tanks & Cranes0509 Overhead Power & Transmission Line Const.0510 Wood Frame Building Construction0511 GlassInstallation:Buildings0512 InsulationInst.&AsbestosAbatementWork0513 InteriorFinishCarpentry0514 GarageDoorInstallation0516 Carpentry N.O.C.0517 Factory Built Home Set-up by Cont./Mfg.0518 Non Wood Frame Building Construction0519 SheetMetalSiding,Gutter&DownspoutInst.0521 Painting:Buildings—InteriorWork0524 DrywallInstallation(Discounted)0526 DrywallTaping(Discounted)0527 DrywallPrime/Texture(Discounted)0528 DrywallStocking(Discounted)0529 DrywallScraping(Discounted)0530 DrywallInstallation0531 Drywall Taping0532 Drywall Prime/Texture0533 Drywall Stocking0534 Drywall Scraping0540 WallboardInstallation—DiscountedRate0541 Wallboard Taping — Discounted Rate0550 WallboardInstallation—UndiscountedRate
0551 Wallboard Taping — Undiscounted Rate0601 Electrical Wiring: Buildings & Structures0602 ElevatorInstallation,Service&Repair0603 MachineryInstallation,Service&Repair0606 VendingMachineInst.,Service&Repair0608 Telephone&ElectricalAlarmSystemInst.0701 Dam Construction0901 Shipbuilding or Repair N.O.C.1303 Tele. Co. — All Other Employees N.O.C.1305 TV Cable Co. — All Other Employees N.O.C.1507 Waterworks Operations, Repair & Main’t.1702 Underground Mines1703 Surface Mines1704 Quarries2907 Cabinet & Counter top Manufacturing — Wood2908 Factory Built Housing Manufacturing3101 Redi-mix Concrete Dealers3105 Concrete Products Manufacturing3415 Factory Built Housing Dealers3506 Mobile Crane & Hoisting Services4900 Const. Project or Site Superintendent/Mgr.4901 Consulting Engineers & Architectural Svcs.4910 Property & Building Management Services5208 IronWorks—Shop
A company may be eligible to participate in the group by exception if they are engaged in a construction-related activity that is not assignedtoariskclassificationlistedabove.Forquestionsaboutriskclasses,contactR.O.I.I.® Select Senior Underwriter/Risk Management Director Kristeen Johnson at [email protected] or (360) 352-7800, ext. 119.
4903-07 BoilerInspectingN.O.C.4903-08 ElevatorInspecting4903-10 InspectionofBuildings5206-79 Permanent Yard or Shop Operations;
Construction or Erection Contractor6601-04 Security Guards at Construction Sites
L&I REQUIREMENTSnHave an open industrial insurance account with L&In Havefiledallrequiredreports,paidallindustrialinsurancepremiums,penaltiesandinterest(orbecurrentwitha
repayment plan) and not owe a debt to any other section of the Department for the applying account (includingsub-accounts) at the start of the plan year (July 1, October 1, January 1)
n Be a current BIAW member (see R.O.I.I.® Select Participation Requirements)n Must separately enroll all sub-accounts that are construction-related (L&I requires construction-related subsidiary
accounts to enroll)n The primary nature of the business for applying account(s) must be “construction and related services” ForverificationofmeetingthiscriteriafortheR.O.I.I.® Selectgroup,pleaserefertothelistofacceptedriskclassifications below or contact the L&I Retro Department at (360) 902-4851. Your company must report hours under one or more of the acceptedriskclassificationsbelowtobeeligible.
R.O.I.I.® Select Administrative contact at your company Direct line # Email
R.O.I.I.® Select Claims contact at your company Direct line # Email
Owner* % of Ownership* Direct line # Email
Owner % of Ownership Direct line # Email
*Required information
Company name
Mailing address Physical address
City, State, Zip City, State, Zip
Phone Fax
Business type: Sole Proprietorship Partnership Corporation LLC S Corp Other:
L&IAccountID#
PreviousL&IAccountID#
FederalID# UBI#
LOCAL HOME BUILDERS ASSOCIATION INFORMATIONTobeapprovedforenrollmentandreceiverefundsinR.O.I.I.®Select,youmustbeaBIAWmemberthroughanaffiliatedlocalhomebuildersassociation.
FORM 1bR.O.I.I.® SELECT 2020-2021 PLAN YEARPERSONNEL/HIRING QUESTIONNAIRE
Company Name: UBI#:
L&I Account ID#:
X
—,
Signature (Owner/Partner/Corporate Officer)
Type or print name
Title - Must be Owner/Partner/Corporate Officer
Date
If you own more than one business, or are the majority owner of more than one business, L&I will assign a main (primary) account number to your principal business and sub account numbers for your secondary business or businesses. If L&I does this and you apply to enroll one of your businesses in a retro group, L&I will analyze all of your commonly-owned businesses to determine which will be required to enroll in retro. This is referred to as the “all or nothing rule” and means if one company participates, all must participate if they fall within the same business and industry category of the group you have applied to. You have the option to enroll non-construction related sub accounts. If you have questions about this requirement please call the business association above or L&I at (360) 902-4851.
As a member of the sponsoring organization listed above, this employer applies for enrollment in the retrospective rating group sponsored by the organization. L&I will notify the sponsoring organization of acceptance or denial of your application to participate in the group. It is the responsibility of the sponsoring organization to notify you of this acceptance or denial. As a prerequisite of enrollment, each of your industrial insurance accounts must be in good standing at the time of enrollment or you will not be allowed to participate in retrospective rating.
By signing this document, the employer named above agrees with all of the following conditions:
n L&I will automatically re-enroll the employer as a member of the group in future coverage periods provided the employer’sindustrial insurance account is in good standing at the time of re-enrollment. If the employer does not want to participatein future coverage periods the employer or sponsoring organization must notify L&I in writing prior to the beginning of therespective coverage period.
n The employer authorizes L&I to furnish the sponsoring organization or their designee with data and information obtainedfrom the employer’s industrial insurance account(s).
n The sponsoring organization will represent the employer in all matters applicable to retrospective rating participationand the employer’s industrial insurance account(s).
n The employer agrees to comply with L&I rules, regulations and laws and is bound by the terms of the agreement betweenthe sponsoring organization and L&I.
n The employer will cooperate with L&I claims management activities and will participate in the sponsoring organization’sclaims management and workplace safety initiatives.
n All retrospective rating adjustments that may be earned by the employer will be given to the sponsoring organization. L&I is not involved in the distribution of a group refund to the individual group members except in the case of defunctgroup.
These conditions are in effect immediately and will remain in effect through the term of any agreement between the sponsoring organization and L&I.
NOTE:L&I disclaims any interest in any other contract you may enter into with the sponsoring organization as their prerequisite of your participation in the retrospective rating group that they sponsor, and L&I neither approves or disapproves of any language or provision contained in these other contracts. Return this application directly to the above organization. DO NOT SEND THIS APPLICATION DIRECTLY TO L&I.
FORM 2R.O.I.I.® SELECT 2020-2021 PLAN YEAR
APPLICATION FOR GROUP MEMBERSHIP Retro ID#: 025
Mail to: Building Industry Association of Washington 111 21st Avenue SW | Olympia, WA | 98501
rating group for the July 1, 2020 through June 30, 2021 Plan Year.THEREFORE,inconsiderationofthemutualpromisesandcovenantscontainedinthiscontract,BIAWandtheParticipatingMemberagreeasfollows:
1. Meaning of Terms and Words(a)“PlanYear”–consistsoftwelvecalendarmonthsbeginningonJuly1,ofagivenyearandendingonJune30thofthefollowingyear(Example:
(b)“StaggeredEnrollment”–L&IallowsBIAWtoenrollnewParticipatingMemberseachcalendarquarterduringaPlanYear.IfaMemberappliesto participate in a Plan Year after the July 1st start date and they are accepted as a Participating Member their participation for the initial Plan Year wouldstartonthefirstdayofthefirstcalendarquarterbeginningafterthedatethiscontractisexecutedbyBIAWoritsdesignee.Thisshortenedpar-ticipationperiodstillhasthesameenddateofJune30thofthePlanYearinwhichtheyparticipate.(Example:aMembercompanysubmitsacontractforconsiderationonSeptember1st.IftheMemberisacceptedtheirfirstenrollmentwouldstartonOctober1standendonJune30ththefollowingyearandcoverninecalendarmonths.)ThethreeannualadjustmentsdescribedinPlanYearaboveapplyexactlyinthesameway.
ThelimitofaParticipatingMember’sobligationforPenaltiesisdescribedinthe“PenaltiesandLiabilityLimits”partofthisAgreement.(g)“ParticipatingMember(s)”–aMemberthatispartoftheR.O.I.I.® Select retrospective rating group in a given Plan Year.(h)“Member”–anybusinessthatpaysduestooneofBIAW’slocalbuildingassociationaffiliatesandduestoBIAW.(i) “ApplicantMember”–anyMemberthatisapplyingtoparticipateintheR.O.I.I.® Select program.(j) “GoodStanding”–aMemberofoneormorelocalbuildingassociationsaffiliatedwithBIAWwhoiscompliantwiththelocalaffiliatedassocia-
resent”doesnotincludemattersthatproceedtotheBoardofIndustrialInsuranceAppeals(BIIA)orhighercourts.TheRetroGroupandParticipatingMemberareseparateentitiesforlegalstandingpurposes.IfaParticipatingMemberwishestoappealanL&IdecisionindependentofBIAWoritsdesignee, the Participating Member must retain and pay for their own legal counsel. Nothing in this section shall be read as relieving the Participating MemberofitsobligationtocooperatewithBIAWand/oritsdesigneeatalllevelsofclaimmanagementandadjudication/appeal.Seealsosections 5(k)and7(e).
2. Plan SelectionBIAWoritsdesigneemakesthisselectionforthegroup.ParticipatingMemberobligationsforanyadditionalpremium/penaltiesisdescribedinthe“PenaltiesandLiabilityLimits”partofthisAgreement.
4. Administrative ResponsibilitiesBIAWoritsdesigneewillprovideassociationMemberswithenrollmentproceduresfortheR.O.I.I.®Selectretrospectiveratinggroupprogram.BIAWoritsdesigneeisresponsiblefortheadministrationoftheR.O.I.I.® Select group including establishing underwriting criteria and participation require-ments.BIAWoritsdesigneewilldetermineifclaimsassistancetoParticipatingMembersandsafetyandlosscontrolserviceswillbeperformedbyMemberServicesCorporation(MSC)stafforcontractedouttoanindependentthirdpartyadministrator.AllactionsanddecisionsofBIAWoritsdes-ignee regarding the disposition of the Premium Return, including but not limited to establishing reserves; investment of funds; timing and amount of anydistributionofthePremiumReturnorpaymentstoParticipatingMembers;andexpendituresforadministrativecostsandexpensesoftheR.O.I.I.® SelectretrogroupshallbewithinthesolediscretionofBIAWoritsdesignee.BIAWoritsdesigneemayatitsdiscretionhirestafforconsultantsnec-essary to carry out its obligations and may pay from the Premium Return such compensation for such services as it deems reasonable and proper. DecisionsofBIAWoritsdesigneearenotsubjecttochallengeandshallbeabsoluteandbindingonallParticipatingMembers.
5. Participating Member ObligationsBycompletingandsubmittingthiscontracttoBIAWoritsdesignee,theApplicantMemberagreestoallofthefollowingadditionalconditionsandrequirements:
Your signature is required at bottom of Form 3c
FORM 3aR.O.I.I.® SELECT 2020-2021 PLAN YEARBIAW GROUP RETROSPECTIVE RATING PROGRAM AGREEMENT
job when they sustain a workplace injury or illness covered by Washington’s workers’ compensation laws and continue to pay them at their regular pre-injury wage.
(d) TheParticipatingMemberagreestoprovidethirty(30)workingdaysofregularwages(KeptOnSalary)foranyoftheirinjuredemployeeswhoare unable to return to any work because of a work related injury or illness and have been restricted from all such work by their attending physician.
(e) Each Participating Member agrees to pay BIAW or its designee an annual enrollment/re-enrollment fee. The annual enrollment/re-enrollmentfeeistheequivalentofoneandone-halfpercent(1.5%)oftheParticipatingMember’sL&IIndustrialInsurancePremium(fourmostrecentcalendarquarters).IftheParticipatingMemberispartofaStaggeredEnrollment,theenrollment/re-enrollmentfeewillbepro-ratedbasedonthepercentageoftheParticipatingMember’scoverageperiodbearstothePlanYear.Innocaseshallthisfeebelessthanonehundredandfiftydollars($150.00).TheenrollmentfeemustbeincludedwiththisAgreementwhenitissubmittedtoBIAWor its designeeasa condition of enrollment.Aspart of theautomatic re-enrollment procedureoutlined in the “ParticipatingMemberObligations” section of thisAgreement, BIAW or its designee may deduct annual re-enrollment fees directly from the ParticipatingMember’sR.O.I.I.® Select Premium Return.
industrialinsuranceaccounttoBIAWoritsdesignee.Workers’compensationinsurancedataforthepurposeofthisAgreementincludesbutisnotlimitedtoclaimhistory,premiumpaymenthistory,experiencefactorcalculationsandinjuredworkerclaimfiles.ThisauthorizationremainsineffectthroughouttheentireperiodoftheParticipatingMember’sobligationforthePlanYear(forty-sixmonths)theyareenrolledin and may not be withdrawn.
Therefore,aPremiumReturnforanyPlanYearisnotguaranteed.L&IregulationsprovidethatanyandallPremiumReturnspayabletoBIAWbyL&IthataregeneratedbytheR.O.I.I.® Select retrospective rating group and Participating Members is the sole property of the sponsoring organization andnottheindividualParticipatingMembers.AllmoniesreceivedfromL&IheldbyBIAWoritsdesigneeshallbesubjecttotheexclusivemanage-mentandcontrolofBIAWoritsdesignee.ParticipatingMembersshallhavenolegalrightorentitlementtoanyofthePremiumReturnoranyinterestincomeorotherbenefitaccruingfromtheinvestmentofthePremiumReturnuntilBIAWoritsdesigneedistributesamountstoParticipatingMembers.BIAWoritsdesignee,initssolediscretion,determinesandauthorizesanyandalldistributionsofthePremiumReturnorportionthereof.ParticipatingMembersmaynotassignorpledgeanyportionofthePremiumReturn,interest,incomeorotherbenefitthatmayaccrueasaresultofinvestmentsofthe Premium Return to a creditor of a Participating Member nor can any creditor of a Participating Member attach either voluntarily or by operation of law any portion of the Premium Return. The timing and amount of any distribution of the Premium Return and any income produced from the investment of the Premium Return shall be determined by BIAW or its designee in its sole and absolute discretion. The actual distribution of the PremiumReturn and/or incomeproduced from investment of the Premium Return or portion thereof to Participating Members is based upon a distribution system adopted by BIAW or its designee. Any and all decisions of BIAW or its designee concerning distribution of the Premium Return and/or income derivedfrom investmentsof thePremiumReturnarenotsubject tochallengeormodificationbyanyparty (i.e.MemberofBIAWoraffiliated localbuild-ing association, R.O.I.I.® Select Participating Member, creditor of a Member or Participating Member, state, federal or local taxing agency). TheParticipatingMemberacknowledgesandagreesBIAWoritsdesigneemaypaytenpercent(10%)ofthePremiumReturnapplicabletothisPlanYeartolocalaffiliatedbuildingassociationswhodonotsponsor,marketorpromoteaplanthatcompetesinwholeorinpartwiththeR.O.I.I.® Select planandtenpercent(10%)toBIAW.Theallocationofanysuchfeesamongandbetweenlocalassociationswillbeinthesoleandabsolutediscre-tionofBIAWoritsdesignee.ThesefeesareinconsiderationforBIAW’ssponsorshipoftheR.O.I.I.®SelectprogramandmaybeusedbyBIAWoritsdesignee for any purpose. TheParticipatingMemberacknowledges thatBIAWand/or itsdesignee is/areentitled toanyadditionalcompensation (float)whichaccruesonfundsheldbyBIAWoritsdesignee.Thisincludes,butisnotlimitedto,interestorearningsonPremiumReturnsreceivedfromL&IbeforethefundsareinvestedasdirectedbyBIAWoritsdesigneeandinterestearnedonfundsdistributedtoParticipatingMemberspriortotheParticipatingMembercashing or depositing the said distribution.
7. Default by Participating MemberAny failure by the Participating Member to comply with the terms herein shall be considered a default, including but not limited to:
(a)Failingtopaykeptonsalaryandoffermodifiedlightdutyworktoinjuredemployeesasoutlinedinthe“ParticipatingMemberObligations,”sections 5c and 5d, of this Agreement;
FORM 3bR.O.I.I.® SELECT 2020-2021 PLAN YEARBIAW GROUP RETROSPECTIVE RATING PROGRAM AGREEMENT
The Defaulting Member shall be deemed to have forfeited any and all rights to any Premium Return and any income produced from investment of thePremiumReturnforallPlanYearsinwhichtheyparticipated,irrespectiveofthePlanYearinwhichthedefaultoccurred.BIAWoritsdesignee shall not be subject to any claim by the Defaulting Member or any creditor or assignee of the Defaulting Member. Any forfeited Premium Return and/or any income produced from investment of the Premium Return or portion thereof shall be held and distributed to Participating Members in goodstandingasauthorizedbyBIAWoritsdesignee.
8. Penalties and Liability Limits of Participating MembersThe Applicant Member understands and agrees to all of the following conditions:
(c) ThatiftheParticipatingMemberfailstopaytheadditionalpremiumwhenrequestedordemandedbyBIAWoritsdesignee,theParticipatingMemberwillpayanadditionalinterestrateoftwelvepercent(12%)perannumandcompoundeddailyontheunpaidbalanceuntiltheyhavesatisfiedthe debt and that they are directly responsible for this debt and any interest and penalties that may accrue as a result of late payments by the Partici-patingMemberuntilthedebthasbeenfullysatisfied.
(e)ThattheParticipatingMember’sliabilityunderthisAgreementshallnotbeextinguishedbytheParticipatingMember’swithdrawal,expulsion,membershiptermination,saleofbusinessorclosure.Ifacorporationorlimitedliabilitycompany,theofficers/partners/owners/membersagreetobebound by this Agreement and to be personally and jointly liable for this debt.
(f) IntheeventthatitisdeterminedthataParticipatingMemberhasunderpaidtheirworkers’compensationinsurancepremiumseitherbyunderreporting work hours of employees or misclassifying employee work hours or using a reporting methodology that resulted in an underpayment of IndustrialInsurancePremiums,BIAWoritsdesigneeatitsoptionmayrequiretheParticipatingMembertopaythedifferenceoftheirretrospectivepremiumandthepremiumtheyactuallypaidtoL&I.Forpurposeofthisparagraph“retrospectivepremium”shallbethesameamountascalculatedbyL&IintheretrospectiveratingformulafoundinWAC296-17B.
ticipatingMemberinwritingatleasttwomonthspriortothestartofthenextPlanYearand(ii)theParticipatingMemberdoesnotnotifyBIAWorits designee in writing no later than one month prior to the start of the next Plan Year that the Participating Member wishes to discontinue participating intheR.O.I.I.® Select retrospective rating group for the next Plan Year.
11. Non WaiverTherightsofBIAWoritsdesigneeunderthisagreementshallbecumulativeandthefailureonthepartofBIAWoritsdesigneetoexerciseproperlyanyrightsgivenhereundershallnotoperatetoforfeitorwaiveanyofBIAW’soritsdesignee’srightsunderthiscontract.
12. Attorney FeesIntheeventthatBIAWoritsdesigneeisrequiredtohirelegalcounseltoenforceanyoftheobligations,requirementsand/orconditionsofthiscontractagainst a Defaulting/Participating Member or defend against a claim made by a Defaulting/ Participating Member, the Defaulting/Participating Member agreestopayalllegalfeesandcostsincurredbyBIAWoritsdesigneeasaresultofanylegalactionorproceeding.TheDefaulting/ParticipatingMember also agrees that the Thurston County Superior Court shall be the exclusive venue for any lawsuits arising under this contract.
13. BIAW IndemnificationTheApplicantMemberherebyreleasesandagreestoindemnifyandholdBIAWand/oritsdesignee,andallitsortheirMembers,staffandconsul-tantshiredbyBIAWoritsdesigneeharmlessfromanyandallliabilityforanydecisionwhichmayorhereafterbemadebyBIAWand/oritsdesigneeincludingitsstafforconsultantswithregardtotheR.O.I.I.® Select retrospective rating group, plan risk selection, Participating Member enrollments and distributionofPremiumReturn(includingthedispositionofordistributionofanyinterest,principalandprofit).
14. Acceptance in R.O.I.I.® SelectTheApplicantMemberunderstandsandacknowledgesthatL&IwillacceptBIAW’ssponsorshipoftheR.O.I.I.® Select retrospective rating group only ifBIAWcomplieswithallstatutoryandregulatoryrequirementsofL&I.TheApplicantMemberalsounderstandsandacknowledgesthatapprovaltoparticipateintheR.O.I.I.®SelectretrospectiveratinggrouprestswithBIAWoritsdesigneeandiscontingentuponL&I’sapprovaloftheApplicantMembertoparticipateinBIAW’sR.O.I.I.® Select program. This Agreement shall be binding upon the Applicant Member, its successors and assignees andiseffectiveuponapprovalofthisAgreementbyL&IandBIAWasoutlinedinthissection(14)ofthisAgreement.
INIT
—
Date
Title—MustbeOwner/Partner/CorporateOfficer
Signature(Owner/Partner/CorporateOfficer)
Print or Type Name
Company Name ,
L&IAccountID#
*PLEASE HAND INITIAL HIGHLIGHTED SECTIONS*FORM 3cR.O.I.I.® SELECT 2020-2021 PLAN YEARBIAW GROUP RETROSPECTIVE RATING PROGRAM AGREEMENT
TERMS & CONDITIONS and SIGNATUREmust be HAND CHECKED and HAND SIGNEDI have read and understand the terms and conditions of this three-page contract.
Name Title
Company Name
Phone Number Email
L&IAccountID# Persontocontactforsupportingdocuments,if different than above
The underwriting questionnaire is designed to help us better understand your company’s hiring, loss control and safety prac-tices.YouranswerswillbekeptconfidentialandwillnotbesharedwithanyoneoutsideofBIAWandR.O.I.I.® Select staff. We willcontactyouifsupportingdocumentsareneededforverificationofyouranswers.Ifyouhaveanyquestionsregardingtheunderwriting questionnaire, please contact Jessica Bass at (360) 352-7800, ext. 132.
—,
1. Do you expect to hire new employees within the next year?
If yes, how many:_________________________________________________________________________
2. Do you obtain a complete work history from all new applicants?
3. Are prior employers contacted to verify previous employment?
If yes, what questions do you ask: _______________________________________________________
FORM 4bR.O.I.I.® SELECT 2020-2021 PLAN YEARUNDERWRITING QUESTIONNAIRE
F ®
ORM 5R.O.I.I. SELECT 2020-2021 PLAN YEARABCs OF CLAIM MANAGEMENT CLASS
As a condition of enrollment, the owner of the R.O.I.I.® Select participant is required to attend this class prior to the final L&I deadline for enrollment.
Please list the owner who will attend the class. If you have any questions about the class requirement, please contact Jessica Bass at [email protected] or (360) 352-7800, ext. 132.
Attendee Title Attendee Title
Email Email
Owner OwnerOther
OCTOBER 2020 ENROLLMENT All October enrollment classes will be held online. Once a schedule has been released we will contact you. Please indicate above who will be attending.
JANUARY 2021 ENROLLMENT Must attend a class prior to December 15, 2020All class times are 11 a.m. - 1 p.m.
o November 3, 2020SICBA15571A Peterson Rd.Burlington, WA 98233
o November 4 2020Central WA HBA - Wenatchee25 N Wenatchee Ave. #207BWenatchee, WA 98801
o November 5, 2020Central WA HBA3301 W. Nob Hill Blvd.Yakima, WA 98902
o November 5, 2020MBA of Pierce County3711 Center StreetTacoma, WA 98409
o November 10, 2020BIA of Whatcom County1650 Baker Creek PlaceBellingham, WA 98226
o November 11, 2020CapitalBenefitsServices15375 SE 30th Pl. #380Bellevue, WA 98007
o November 12, 2020BIA of Clark County103 E. 29th StreetVancouver, WA 98663
o November 12, 2020Spokane HBA5813 E. 4th Ave #201Spokane Valley, WA 99212
