Application for Certification of Self-Insurance (Sample)FS-100 (1/10) PAGE 1 OF 7 1. Are you currently self-insured in New York State? Yes No If yes, give certificate number _____

APPLICATION FOR CERTIFICATE OF SELF-INSURANCE

New York State Department of Motor Vehicles

Insurance Services Bureau

6 Empire State Plaza, Room 335

Albany NY 12228

FS-100 (1/10) PAGE 1 OF 7

1. Are you currently self-insured in New York State? Yes No

If yes, give certificate number ________________________________________

2. If approved, please indicate the number of vehicles you expect to register in New York State under your self-insurance

certification. In addition, attach a list of vehicles including vehicle identification number (VIN), license plate number,

vehicle class, year and make.

Number of vehicles to be registered: ______________

3. Are any of the vehicles in item 2 above Tow Trucks? Yes No

If yes, specify the number of tow trucks to be registered ______________

Note: Tow trucks require a different minimum level of insurance coverage under the NYS Vehicle and Traffic Law. Therefore,

the financial requirements are different for tow trucks. If appropriate, please make the necessary calculations in

Section E.

4. Are any of the vehicles in item 2 above used for transporting passengers? Yes No

a) If yes, are these vehicles operated privately or as not-for-profit? Yes No

b) If no, are these vehicles operated for hire? Yes No

If you answered yes to 4(b), enter the information and make the appropriate calculations in Section F.

Note: For-hire vehicles used to transport passengers require a different minimum level of insurance coverage under the NYS

Vehicle and Traffic Law. Therefore, the financial requirements are different for these vehicles. If appropriate, please make

the necessary calculations in Section E based upon the schedule in Section F.

A. Applicant Information

Full Name of Applicant (as will appear on insurance ID cards and registration)Check One:

ORIGINAL APPLICATION

RENEWALMailing Address (No. & Street)

Federal Employer NumberCity State ZIP Code

Phone Fax E-Mail

Full Name of Applicant (as will appear on insurance ID cards and registration)

B. Application Fees

An application fee of five dollars ($5) per vehicle is required for vehicles being registered under this Application for

Certificate of Self-Insurance. A certified check for the total amount payable to the "Commissioner of Motor Vehicles" must

accompany the application.

C. Contact Administrator Information

Name of Applicant's Contact Person

Mailing Address (No. & Street)

PO Box/Apt./Suite

City State ZIP Code

Phone Fax E-Mail

D. Claims Liaison Information

Name of Applicant's Claims Liaison

Mailing Address (No. & Street)

PO Box/Apt./Suite

City State ZIP Code

Phone Fax E-Mail

Special Note for Section E and Section F calculations:

1. If you are required to complete Section F (Insurance Liability Requirements for Vehicles Transporting Passengers For Hire),

complete that section BEFORE you complete Section E (Asset and Equity Calculations for All Vehicles).

2. For calculations involving the square root of the number of vehicles, ROUND the square root result to the nearest WHOLE

number.

Example: 112 vehicles. . . . . square root of 112 = 10.583, so round up to 11

Example: 102 vehicles. . . . . square root of 102 = 10.099, so round down to 10

FS-100 (1/10) PAGE 2 OF 7

Full Name of Applicant (as will appear on insurance ID cards and registration)

E. Asset and Equity Calculations for All Vehicles

1. Liquidity

A) ___________________________________ Number of tow trucks

___________________________________ X $300,000 = ____________________ Square root of the number of tow trucks

B) For-Hire Liquidity Total - from Section F(1) = ____________________

C) ___________________________________ Number of other vehicles

___________________________________ X $160,000 = ____________________ Square root of the number of other vehicles

D) Total of A + B +C = ____________________

E) Average dollar amount of claims over the past 4 years - from Section H(2A) = ____________________

F) Larger of D or E above = ____________________

Current Assets as shown in financial statements = ______________________

Current Assets are > F above

2. Equity

A) ______________________________ X $150,000 = ____________________ Number of tow trucks

B) For-Hire Equity Total - from Section F(2) = ____________________

C) ______________________________ X $85,000 = ____________________ Number of other vehicles

D) Total of A + B + C = ____________________

Unrestricted Equity as shown in financial statements = __________________

Unrestricted Equity is > D above

FS-100 (1/10) PAGE 3 OF 7

Full Name of Applicant (as will appear on insurance ID cards and registration)

F. Insurance Liability Requirements for Vehicles Transporting Passengers For Hire

1. Liquidity

A) __________________________________________ Number of vehicles with capacity of not more than

7 passengers

__________________________________________

Square root of the number of vehicles with capacity

of not more than 7 passengers

X $160,000 = ____________________

B) __________________________________________ Number of vehicles with capacity of at least 8 but

not more than 12 passengers

__________________________________________

Square root of the number of vehicles with capacity

of at least 8 but not more than 12 passengers

X $210,000 = ____________________

C) __________________________________________ Number of vehicles with capacity of at least 13 but

not more than 20 passengers

__________________________________________

Square root of the number of vehicles with capacity

of at least 13 but not more than 20 passengers

X $210,000 = ____________________

D) __________________________________________ Number of vehicles with capacity of at least 21 but

not more than 30 passengers

__________________________________________

Square root of the number of vehicles with capacity

of at least 21 but not more than 30 passengers

X $260,000 = ____________________

E) __________________________________________ Number of vehicles with capacity of more than

30 passengers

__________________________________________

Square root of the number of vehicles with capacity

of more than 30 passengers

X $310,000

For-Hire Liquidity Total

= ____________________

________________________

A+B+C+D+E from this block

2. Equity

A) __________________________________________ Number of vehicles with capacity of not more than

7 passengers

X $ 85,000 = ____________________

B) __________________________________________ Number of vehicles with capacity of at least 8 but

not more than 12 passengers

X $115,000 = ____________________

C) __________________________________________ Number of vehicles with capacity of at least 13 but

not more than 20 passengers

X $155,000 = ____________________

D) __________________________________________ Number of vehicles with capacity of at least 21 but

not more than 30 passengers

X $195,000 = ____________________

E) __________________________________________ Number of vehicles with capacity of more than

30 passengers

FS-100 (1/10)

X $235,000

For-Hire Equity Total

= ____________________

________________________

A+B+C+D+E from this block

PAGE 4 OF 7

___________________________________________________

___________________________________________________

Full Name of Applicant (as will appear on insurance ID cards and registration)

G. Affirmation by Independent Certified Public Accountant

Name of Certified Public Accounting Firm

Mailing Address (No. & Street)

PO Box/Apt./Suite

City State ZIP Code

Phone Fax E-Mail

In our opinion, the amounts of Current Assets and Unrestricted Equity used in the calculations contained in Section E of this application, and noted directly below, are supported by the audited financial statements of this entity.

Current Assets as shown in Financial Statements: ________________________________________

Unrestricted Equity as shown in Financial Statements: ________________________________________

State of ________________)

County of ______________________) ss

On this _________________________ day of ________________________________, in the year __________,

before me, personally came

_________________________________________________________________________________ to me known to be the same

person who executed the foregoing affirmation, and s/he _________________________________________________________

acknowledged to me that s/he executed the same.

Signature of Certified Public Accountant

Signature of Notary Public

SEAL

FS-100 (1/10) PAGE 5 OF 7

Full Name of Applicant (as will appear on insurance ID cards and registration)

H. Accident and Claims Experience

ACCIDENT CLAIMS EXPERIENCE TABLE FOR PAST FOUR CALENDAR YEARS

1. Number of Accidents for Past 4 Completed Calendar Years 20_____ 20_____ 20_____ 20_____

Bodily Injury Only

Property Damage Only

Both Bodily Injury and Property Damage

TOTAL

2.

2A.

Number and Dollar

Amounts of Payments

Made on Claims for

Past 4 Completed

Calendar Years

20_____ 20_____ 20_____ 20_____

Num

ber

$ A

mount

Num

ber

$ A

mount

Num

ber

$ A

mount

Num

ber

$ A

mount

Bodily Injury Only

Property Damage Only

Both Bodily Injury and

Property Damage

TOTAL

Average dollar amount of claims over the past 4 completed calendar years.

Report this amount here AND in Section E(1E) ___________________________________

3. Number and Dollar

Amounts of

Pending Claims

(Reserves)

for Past 4 Completed

Calendar Years

20_____ 20_____ 20_____ 20_____

Num

ber

$ A

mount

Num

ber

$ A

mount

Num

ber

$ A

mount

Num

ber

$ A

mount

Bodily Injury Only

Property Damage Only

Both Bodily Injury and

Property Damage

TOTAL

FS-100 (1/10) PAGE 6 OF 7

___________________________________________________

___________________________________________________

___________________________________________________

Full Name of Applicant (as will appear on insurance ID cards and registration)

I. Excess Insurance Policy

An excess insurance policy in the amount of at least $5 million is required, and a copy of the policy must be submitted along with

this completed application. The policy’s self-insurance retention fee must not be greater than the amount of the Current Assets of

the company, as affirmed by a CPA in Section G above.

J. Declaration by Self-Insurance Applicant

I/we do hereby apply jointly and severally for self-insurance certification under Section 316 of Article 6 and/or Section 370(3) of

Article 8 of the New York State Vehicle and Traffic Law.

I/we agree that in accordance with the New York State Vehicle and Traffic Law, upon due notice and hearing, the commissioner

may, at her/his discretion and upon reasonable grounds, cancel a certificate of self-insurance.

I/we agree to have, and continue to maintain, financial ability to respond to all payment of motor vehicle claims and judgments

arising from the ownership, maintenance, use or operation of the applicant's motor vehicles.

I/we affirm that the levels of Assets and Equity required by the self-insurance program of the New York State Department of

Motor Vehicles, and contained within this agreement and verified by a Certified Public Accountant as provided in this

application, shall be maintained during the period of self-insurance certification. In addition, the applicant agrees to provide

audited financial statements to the NYS Department of Motor Vehicles upon request.

I/we understand and agree that this entity's self-insurance program will be structured for the settlement of claims compatible with

the mandatory liability limits of Articles 6 and 8 of the New York State Vehicle and Traffic Law, and with Section 3420 and

Article 51 (no-fault insurance law) of the New York State Insurance Law.

I/we agree that the applicant's self-insurance program will provide the primary motor vehicle coverage at all times and that the

appropriate level of excess liability insurance be maintained and to notify NYS DMV within 10 days if such insurance is

cancelled by any party.

I/we agree to maintain strict compliance for the settling of claims, and therefore agree to promptly open communication (within

15 calendar days of being notified of motor vehicle damages by any person or firm) with any person or firm regarding motor

vehicle damages claimed.

I/we agree to promptly investigate any and all motor vehicle damage claims and to settle all motor vehicle claims promptly, fairly

and equitably.

1/we affirm that, to the best of this applicant's knowledge, all information contained in and included with this application is true and correct, and I/we further understand that any false statements made in this document or under this agreement are punishable under Section 210.45 of the New York State Penal Law and any other applicable provision of law.

State of _______________________)

County of _________________________) ss

On this _______________________ day of _______________________________________, in the year __________,

before me, personally came _______________________________________________________________________________ to

me known who, being duly sworn, did depose and say that s/he resides in ___________________________________________

and is an employee of ___________________________________________________________, the company described herein

and which executed the above instrument; that s/he knows the seal affixed hereto; that it was so affixed by order of the Board of

Directors of said company; and that s/he signs her/his name hereto by like order.

Signature of company representative deposed above

Title of company representative deposed above

Signature of Notary Public

PAGE 7 OF 7 FS-100 (1/10)

Reset/clear

APPLICATION FOR CERTIFICATE OF SELF-INSURANCEA.Applicant InformationB. Application FeesC. Contact Administrator InformationD. Claims Liaison InformationSpecial Note for Section E and Section F calculations:E. Asset and Equity Calculations for All Vehicles1. Liquidity2. Equity

F. Insurance Liability Requirements for Vehicles Transporting Passengers For Hire1. Liquidity2. Equity

G. Affirmation by Independent Certified Public AccountantH. Accident and Claims ExperienceACCIDENT CLAIMS EXPERIENCE TABLE FOR PAST FOUR CALENDAR YEARS

I. Excess Insurance PolicyJ. Declaration by Self-Insurance Applicant

application information federal employer number: 12-34567890reset: past 4 years 1st column: 06past 4 years 1st column TOTAL: 24past 4 years 1st column BI only: 12past 4 years 1st column PD only: 12past 4 years 1st column BI & PD: 0past 4 years 2nd column: 07past 4 years 2nd column TOTAL: 111past 4 years 2nd column BI only: 100past 4 years 2nd column PD only: 10past 4 years 2nd column BI & PD: 1past 4 years 3rd column: 08past 4 years 3rd column TOTAL: 63past 4 years 3rd column BI only: 50past 4 years 3rd column PD only: 12past 4 years 3rd column BI & PD: 1past 4 years 4th column: 09past 4 years 4th column TOTAL: 78past 4 years 4th column BI only: 33past 4 years 4th column PD only: 44past 4 years 4th column BI & PD: 1#and $ 2nd column: 07#and $ 2nd column BI only: 5#and $ 2nd column PD only: 3AMOUNT 2nd column BI only: 25000AMOUNT 2nd column PD only: 3000AMOUNT 2nd column BI & PD: 50000AMOUNT 2nd column TOTAL: 78000#and $ 1st column: 06#and $ 1st column TOTAL: 18#and $ 1st column BI only: 10AMOUNT 1st column BI only: 50000#and $ 1st column PD only: 6AMOUNT 1st column PD only: 6000#and $ 1st column BI & PD: 2AMOUNT 1st column BI & PD: 100000AMOUNT 1st column TOTAL: 156000#and $ 3rd column: 08#and $ 3rd column BI only: 3AMOUNT 3rd column BI only: 15000AMOUNT 3rd column TOTAL: 17000#and $ 3rd column PD only: 2AMOUNT 3rd column PD only: 2000AMOUNT 3rd column BI & PD: 0#and $ 4th column: 09#and $ 4th column BI only: 1AMOUNT 4th column BI only: 5000#and $ 4th column PD only: 0AMOUNT 4th column PD only: 0AMOUNT 4th column BI & PD: 120000AMOUNT 4th column TOTAL: 125000#and $ 2nd column BI & PD: 1page 6 column 2 # TOTALS: 9#and $ 3rd column BI & PD: 0page 6 column 3 total: 5#and $ 4th column BI & PD: 2page 6 column 4 total: 3PENDING CLAIM COLUMN 1: 06Pending column 1$ TOTAL: 1000Pending column 1 BI only $: 0Pending column 1 PD only $: 1000Pending column 1 BI & PD only $: 0Pending column 1 BI only#: 0Pending column 1 PD only#: 1Pending column 1 BI & PD only#: 0TOTALPending column 1 BI & PD only#: 1PENDING CLAIM COLUMN 3: 08Pending column 3 BI only#: 0Pending column 3 BI only $: 0Pending column 3 PD only#: 3Pending column 3 PD only $: 3000Pending column 3 BI & PD only#: 2Pending column 3 BI & PD only $: 50000TOTALPending column 3 BI & PD only#: 5Pending column 3$ TOTAL: 53000TOTALPending column 2 BI & PD only#: 6PENDING CLAIM COLUMN 2: 07Pending column 2 BI only#: 1Pending column 2 PD only#: 2Pending column 2 BI only $: 5000Pending column 2 PD only $: 2000Pending column 2 BI & PD only#: 3Pending column 2 BI & PD only $: 75000Pending column 2$ TOTAL: 82000PENDING CLAIM COLUMN 4: 09Pending column 4 BI only#: 0Pending column 4 PD only#: 4Pending column 4 BI & PD only#: 3TOTALPending column 4 BI & PD only#: 7Pending column 4$ TOTAL: 79000Pending column 4 BI & PD only $: 75000Pending column 4 PD only $: 4000Pending column 4 BI only $: 02a) HIDDEN Field: 37600025 cents hidden field: 0.25original application or renewal: Original Applicationcurrently self insured in new york: Yesnumber of vehicles to be registered: 250tow trucks above: Yesspecify number of trucks, if yes: 9used for transporting passengers: Yesif yes private or not for profit: Noif no operated for hire: YesState_1: [NY]State_2: [NY]State_3: [NY]application information mailing address of applicant: 123 MAIN STREETapplication information city of applicant: ANYTOWNapplication information zip of applicant: 12345-6789application information phone of applicant: 1-800-555-1212application information fax of applicant: 1-800-555-1213application information email of applicant: [email protected] information full name of applicant: MM MOTORIST INCcontact information full name: MICHAEL MOTORISTcontact information mailing address line 1: 123 MAIN STREETcontact information mailing address line 2: PO BOX 123contact information city: ANYTOWNcontact information zip: 12345-6789contact information phone: 1-800-555-1212contact information fax: 1-800-555-1213contact information email: [email protected] information full name: MICHELLE MOTORISTClaims information mailing address line 1: 123 MAIN STREETClaims information mailing address line 2: PO BOX 123Claims information city: ANYTOWNClaims information zip: 12345-6789Claims information phone: 1-800-555-1212Claims information fax: 1-800-555-1213Claims information email: [email protected] Full name: ABC CERTIFIED PUBLIC ACCOUNTING INCG mailing address line 1: 123 ELM STREETG mailing address line 2: PO BOX 999G city: ANYTOWNG zip: 12345-6789G phone: 1-888-555-1212G fax: 1-888-555-1213G email: [email protected] current assets: 28300000G unrestricted equity: 68925000G county of: NEW YORKG on this day: 31STG on this day of: OCTOBERG in the year: 2010G personally came: JOHN J. DOEG she/he: PG7 county of: NEW YORKPG7 on this day: 31STPG7 on this day of: OCTOBERPG7 in the year: 2010PG7 personally came: MICHELLE MOTORISTPG7 resides: 123 MAIN STREET ANYTOWN NYPG7 is employee of: MM MOTORIST INCasset and equity #1 A: 9asset and equity #1 A - -filled in field: 300000asset and equity #1 A - square root: 3total of asset and equity #1A: 900000asset and equity #1 B: 2520000asset and equity #1 C: 207asset and equity #1C - square root: 14asset and equity #1 C - -filled in field: 160000total of asset and equity #1 - C: 2240000total of asset and equity #1 - D: 5660000page 6 2A total and page 3 E)1e: 94000total of asset and equity #1 - F: 5660000#1 Current Assests as shown in financial statements: 28300000page 3-equity A: 9equity #2 A - -filled in field: 150000equity #2 C - TOTAL OF A: 1350000equity #2 TOTAL OF B: 4040000page 3-equity C: 207equity #2 C - -filled in field: 85000equity #2 C - TOTAL OF C: 17595000equity #2 TOTAL OF A+B+C: 22985000section 2, unrestricted equity as shown in financial statement: 68925000Liquiidity #1 A: 16liquidity #1 A - square root: 4liquidity #1 A - -filled in field: 160000total of liquidity #1A: 640000Liquiidity #1 B: 9liquidity #1 B - square root: 3liquidity #1 B - -filled in field: 210000total of liquidity #1B: 630000Liquiidity #1 C: 4liquidity #1 C - square root: 2liquidity #1 C - -filled in field: 210000total of liquidity #1C: 420000Liquiidity #1 D: 4liquidity #1 D - square root: 2liquidity #1 D - -filled in field: 260000total of liquidity #1D: 520000Liquiidity #1 E: 1liquidity #1 E - square root: 1liquidity #1 E - -filled in field: 310000total of liquidity #1E: 310000For hire liquidity total: 2520000INSURANCE LIBILITY equity #1A: 16pg4 total of equity A: 1360000INSURANCE LIBILITY equity #1B: 9pg4 total of equity B: 1035000INSURANCE LIBILITY equity #1C: 4pg4 total of equity C: 620000INSURANCE LIBILITY equity #1D: 4pg4 total of equity D: 780000INSURANCE LIBILITY equity #1E: 1pg4 total of equity E: 235000TOTAL equity pg4 -hire: 4030000equity A- hidden: equity A- hidden: 85000equity B- hidden: 115000equity C- hidden: 155000equity D- hidden: 195000equity E- hidden: 235000

G State: [NY]certificate if yes: 99PG7 State of 2: [New York ]G State of 2: [New York ]PG7 title company rep: