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:
2. What is your self-insured retention (SIR) in each program?
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.
Name of Your Organization Name of Multnomah County
Department Issuing Contract