This form or a replica containing the same information must be submitted as "proof of insurance" by self-insured organizations.  If the answers to Questions Nos. 3 or 4 are "no," if the answer to Question No. 5 is greater than three years, or if the answer to Question No. 6 is less than 70%, please contact Risk Management for further information.

Your organization has been selected as a contractor for services funded by Multnomah County.  As a County contractor, you must provide proof of certain required insurance coverages or, for self-insured organizations, certification of your organization's self-insurance program.   You have indicated that your organization is self-insured.  Please have an authorized representative of your organization answer the following questions:

1. How long have you been self-insured for:

Workers' Compensation?

General/Auto Liability?

Professional Liability?

2. What is your self-insured retention (SIR) in each program?

Workers' Compensation

General/Auto Liability

Professional Liability

3. Do you maintain a dedicated fund to pay losses?   ( Yes / No )

4. Do you require actuarial studies of the fund to establish funding requirements?  ( Yes / No )

5. How often are your actuarial studies conducted?

6. At what confidence level do you fund?    (Provide percentage.)

Please attach a copy of your State of Oregon Certificate of Self-Insurance for Workers' Compensation.

I certify that the preceding is true.

_____________________________         ______________________________
Signature                                              Title

_____________________________         ______________________________
Name                                                   Date

_____________________________        ______________________________
Name of Your Organization                   Name of Multnomah County
                                                          Department Issuing Contract