(a) An employer must apply to the department to receive an incentive for each WSLPIP on a form and in a manner developed by the department and the application shall contain the information required by subdivision (d) of this section.

1. (1) An insured employer shall apply to the department no later than 120 calendar days prior to the employer's annual policy renewal date in order to receive the credit for the next annual policy period. The employer shall simultaneously send a copy of the application to the employer's workers' compensation insurer.
2. (2) An individually self-insured employer shall apply to the department no later than 120 calendar days prior to the end of the calendar year in order to receive a reduction in security deposit for the next calendar year. The employer shall simultaneously send a copy of the application to the board.
3. (3) For those employers who have an annual policy renewal date that falls between January 1, 2010 and March 3l, 2010 and who have a preexisting program that meets the criteria for any of the three incentive programs set out in these regulations, the department will accept their initial application if postmarked no later than 90 calendar days prior to their annual policy renewal date.

(d) The employer’s WSLPIP application shall include the following information:

1. (1) the particular WSLPIP implemented;
2. (2) a copy of the final and operative WSLPIP documents and a description of the means by which the particular WSLPIP was implemented;
3. (3) the date on which the WSLPIP was in full operation;
4. (4) the name, address, and contact information of the employer’s designated contact for each implemented program;
5. (5) the name, address, and contact information for all New York locations where the WSLPIP has been implemented by the employer, the employer’s applicable Federal Employer Identification Number(s) (“FEIN”), and the insured employer’s workers’ compensation policy number(s) (or the individually self-insured employer’s workers’ compensation carrier identification number);
6. (6) the number of employees and the employer’s North American Industry Classification System (“NAICS”) code classification for each location where the WSLPIP has been implemented;
7. (7) the names, addresses, and contact information of the individual(s) designated to represent employees, or the recognized representative of each collective bargaining unit, where applicable, at the location(s) where the WSLPIP has been implemented;
8. (8) the name, address, and contact information of the insured employer’s workers’ compensation insurer and the annual policy period;
9. (9) the insured employer’s most recent experience rating and current annual workers’ compensation premium, or the current amount of the security deposit that the board determines that the individually self-insured employer is required to pay;
10. (10) the name, address, and certification number of the specialist or the department employee who performed the evaluation of the WSLPIP as required in section 60-1.5 of this Subpart;
11. (11) a copy of the evaluation report completed in accordance with section 60-1.16 of this Subpart; and
12. (12) a verification.

(e) Once the employer's WSLPIP is approved by the department, the department shall notify the employer and issue the employer a certificate of approval indicating that the WSLPIP approval shall be in effect for three years. The incentive shall be effective at the commencement of:

1. (1) the next policy renewal period following the date of the department’s approval certificate if the employer is individually insured; or
2. (2) the next calendar year following the date of the department’s approval certificate if the employer is individually self-insured.

(f) In order to receive the incentive, the employer shall send a copy of the department’s certificate of approval in a timely manner to:

1. (1) the employer’s workers’ compensation insurance carrier if the employer is insured; or
2. (2) the board if the employer is individually self-insured.