Advisory Standards Recognition Application
(SELF-EVALUATION FORM)
(2014 VERSION)
Name of Pool
City, State
The purpose of the AGRiP Advisory Standards Recognition Application is to determine if your pool’s policies,
practices, organizational documents, contracts, and agreements meet AGRiP’s Standards for Recognition. The
application must be fully completed and returned with the application fee in the amount of $600.00 to AGRiP, 9 Cornell
Road, Latham, NY 12110
When asked for appropriate documents in the answer section that follows each Standard, cite all relevant:
 federal or state rules or laws;
 organizational documents;
 governing body promulgated policies and procedures, resolutions and minutes;
 bylaws;
 contracts, agreements, and documents; and,
 any other relevant documents and/or reasoning your pool does not comply with the standard.
Upon the submission of a completed application, the approval process is as follows:
1. AGRiP’s Membership Practices Committee (MPC) reviews the application.
2. Potential questions from the Committee may be submitted back to the applicant for clarification.
3. Once any follow-up responses are received and the review is complete, the results will be discussed by the
Membership Practices Committee for recommendation to the AGRiP Executive Director for final approval.
4. The Executive Director or Managing Director will give final approval, and your pool will be notified.
5. Your pool will receive a recognition plaque at an upcoming AGRiP conference of your choice.
Once your application is submitted, the anticipated timeframe for recommendation by the Committee to the Executive
Director is 6-8 weeks. A final decision will be made after that.
Page 1 of 20
Document1
POOL OVERVIEW
Provide a brief overview and description of the pool in the space below. In your response please include: year pool was
formed; lines of coverage and year each line of coverage was first implemented; relationship to any other organizations, such
as a sponsoring organization; and any other information that tells the pool’s story.
Brief Overview
Coverage
Workers’ Compensation
Check below if your pool has coverage
[
[
[
[
[
Property
Liability
Health
Other (Please describe)
Year first implemented
]
]
]
]
]
I. GOVERNMENT REGULATIONS & GOVERNING DOCUMENTS
The AGRiP Advisory Standards covering Government Regulations and Governing Documents address the legal requirements
placed on pool formation and operation. Please provide your answers in the tables below.
Standards addressed:
I-A
Pool maintains signed formation documents (Interlocal agreements, articles of incorporation, et. al.)
I-B
Pool records reflect any subsequent revisions to these documents were properly filed with appropriate local, state,
and national authorities.
I-C
The pool maintains documents reflecting its federal and state tax status, and if applicable, timely files applicable tax
returns.
I-D
The pool files timely reports in whatever form required by the state of domicile and maintains copies of the reports.
I-E
The pool complies with all regulatory requirements and its records reflect compliance.
I-F
The pool maintains signed originals of the pooling agreement with every member.
I-G
Affirm that Governing Document provisions include: membership eligibility; obligations of members; membership
termination; selection procedures and qualifications for pool’s governing body; powers and duties of the governing
body and committees; indemnification for liability of members of the governing body, officers, committee members
and pool staff; use and ownership of assets of the pool and how the pool may distribute surplus to its members;
assessments – if authorized by the pool; actuarial reviews; financial audits; and, dissolution of the pool.
I-H
Practices of the pool comply with governing documents (explain how.)
Standard I-A
Pool maintains
signed formation
documents (Interlocal
agreements, articles
of incorporation,
et.al.)
Page 2 of 20
Name pool’s
formation
document
Date
Adopted
Date of
Most Recent
Review
Document1
N/A to
pool
If No or N/A, explain
Standard I-B
Pool records reflect
any subsequent
revisions to these
documents were
properly filed with
appropriate local,
state, and national
authorities
Standard I-C
The pool maintains
documents reflecting
its federal and state
tax status, and if
applicable, timely
files applicable tax
returns.
Standard I-D
The pool files timely
reports in whatever
form required by the
state of domicile and
maintains copies of
the reports
Standard I-E
Pool complies with
all regulatory
requirements and its
records reflect
compliance
Page 3 of 20
Name
document
If Yes, enter
Date of most
recent revision
IRS Private letter tax
exemption ruling
(Cite date of letter and
IRS code for exclusion
or exemption, such as
section 115, 501c, etc.)
List Required
Report(s)
List Regulatory
Requirement(s)
State
statutory
exemptio
n (Cite
statute)
Where was the revision filed, and why?
If required, are tax returns filed
timely? What is the date of the
most recent tax return filed?
Date of
most recent filing
How does your pool comply?
(Cite pool records that reflect
compliance.)
Document1
N/A to
pool
N/A
to pool
N/A to
pool
N/A, per
the above
If N/A,
explain
If N/A, explain
If N/A, explain
Standard I-F
The pool maintains signed
originals of the pooling
agreement with every member.
Standard I-G
Affirm that governing
document provisions include:
Affirm signed originals are maintained by the pool
Section of governing document containing provision:
1.
2.
3.
4.
Membership eligibility
Obligations of Members
Membership Termination
Selection procedures and
qualifications for pool’s
governing body
5. Powers and duties of the
governing body and
committees
6. Indemnification for liability
of members of the governing
body, officers, committee
members and pool staff
7. Use and ownership of assets
of the pool and how the pool
may distribute surplus to
members
8. Assessments, if authorized by
the pool
9. Actuarial reviews
10. Financial audits
11. Dissolution of pool
Standard I-H
The practices of the pool are in
compliance with its governing
documents.
Page 4 of 20
Use the space below to explain how the practices of the pool are in compliance with
your governing documents
Document1
II. STAFF AND SERVICE PROVIDERS
The AGRiP Advisory Standards covering Staff and Service Providers recognize the common practice of employing staff and
using outside or third-party providers.
Standards addressed:
II-A
If the pool employs its own staff, there is documentation of the pool's authority regarding employment of staff. Such
documentation addresses authority for terms of employment; compensation (including bonuses); employee benefits
(including leave); performance management; expense reimbursement; scope of staff authority; conflict of interest;
and, indemnification for liability. Documentation includes evidence of board control over primary executive
compensation and benefits package.
II-B
If a pool utilizes contract services, the service provider contracts meet certain provisions including: pool maintains
original signed contracts with service providers, including sponsoring associations; the term of the contract,
including start and end dates, is clearly stated; the scope of services and responsibilities are clearly outlined;
compensation is clearly stated; periodic reporting is done to the pool; ownership and confidentiality of pool
information and data is addressed; compliance with the pool’s state conflict of interest policy and other pertinent
regulations is met; indemnification of the pool for the provider’s negligence and proof of Errors & Omissions
insurance is included; assignability; competition between the service provider and the pool during and after the
contract; cancellation, including runoff provisions for claims contractors; and, clearly states at what point in time
during the process the producer and/or Broker/Agents disclose the cost of compensation (commission if applicable)
to: the pool governing body, pool staff, and pool members and/or prospective members.
II-C
The pool utilizes a transparent, competitive selection process for the procurement of goods and services based upon
relevant documents directing this activity.
II-D
The pool has a Service Providers’ Bill of Rights, which is generally consistent with the AGRiP Model Service
Providers’ Bill of Rights.
II-E
The pool obtains competent legal advice regarding governance and operational issues as necessary, including:
claims defense; coverage issues; and general legal issues as each may relate to the pool. The pool has policies and/or
procedures regarding retainers and conflicts of interest.
[ ]Please check this box if you do not employ your own staff.
PLEASE ANSWER THE BELOW ONLY IF YOU EMPLOY YOUR OWN STAFF.
Standard II-A
If the pool employs its own staff, there is documentation of the
Section of HR policies outlining pool’s authority:
pool’s authority regarding employment of staff. Such
documentation addresses authority for:
1. Terms of employment
2. Compensation (including bonuses)
3. Employee benefits (including leave)
4. Performance management
5. Expense reimbursement
6. Scope of staff authority
7. Conflict of interest
8. Indemnification for liability
9. Evidence of board control over primary executive
compensation and benefits package
Page 5 of 20
Document1
Affirm that each requirement is met by supplying the name of the vendor contracted with and the section of the contract that meets the standard in the space provided.
In each box: if the services are provided “in-house” rather than by a contractor enter “in-house,” and if the answer is N/A or ‘no,’ please explain why.
Standard II-B
If a pool utilizes contract services, the service
provider contracts meet certain provisions
including:
Administrator
Risk
Control
Investment
Manager
Claims
Administrator
Producer and/or
Agent for Sales,
Marketing, or
Service
Excess
Insurance/
Reinsurance
Broker
1. Pool maintains original signed contracts with
service providers, including sponsoring
associations.
2. Term of contract, including start and end date, is
clearly stated
3. Scope of services and responsibilities is clearly
outlined
4. Compensation is clearly stated
5. Periodic reporting is done to the pool (state how
often)
6. Ownership and confidentiality of pool
information and data is addressed
7. Compliance with the pool’s state conflict of
interest policy and other pertinent regulations is
met
8. Indemnification of the pool for the provider’s
negligence and proof of Errors & Omissions
insurance is included
9. Assignability is addressed
10. Competition between the service provider and
the pool during and after the contract
11. Cancellation, including runoff provisions for
claims contractors
At what point in time during the process do the
producer and/or Broker/Agents disclose the cost of
compensation (commission if applicable) to:
Page 6 of 20
The pool governing body
Document1
Pool staff
Members and/or
Prospective Members
Standard II-C
The pool utilizes a transparent,
competitive selection process for the
procurement of goods and services based
upon relevant documents directing this
activity.
Cite policy – or section of policy – fulfilling standard, or how standard is met:
Standard II-D
The pool has a Service Providers’ Bill of
Rights, which is generally consistent with
the AGRiP Model Service
Providers’ Bill of Rights.
Check box if
policy exists and is
generally
consistent.
Standard II-E
The pool obtains competent legal advice
regarding governance and operational
issues as necessary, including:
 Coverage issues
 General legal issues as each may
relate to the pool governance
operations
 The pool has policies and
procedures regarding:
o Retainers
o Conflicts of interest
Date Adopted
N/A to
pool
If N/A, explain
[ ]
Explain how standard is met:
Cite any applicable laws
III. MEMBER SERVICES
The AGRiP Advisory Standards covering Member Services recognize the added value many members expect from the pool.
The programs that your pool provides and how you communicate with your members is covered in these Standards.
Standards addressed:
III-A
The pool communicates policy decisions, actions of the governing body and other activities to members via annual
reports; regular newsletters; and, other media.
III -B The pool keeps minutes of all meetings of the governing body and substantive committees, and all minutes are
distributed or otherwise made available to members.
III -C The pool conducts educational programs for members including safety; risk management; and other such
appropriate topics, and provides incentives to encourage member participation in such activities.
III -D The pool provides risk control or loss prevention services, and supports risk management and loss prevention
practices among members.
III -E The pool conducts regular loss prevention and risk control surveys and/or inspections.
III -F If property coverage is provided, the pool maintains accurate records of member property values.
Page 7 of 20
Document1
Standard III-A
The pool communicates policy decisions,
actions of the governing body and other
activities to members via annual reports;
regular newsletters; and, other media.
Date of last annual
report
Frequency of
newsletters, and
date of last
Other media utilized and
frequency
Standard III--B
The pool keeps minutes of all meetings and all
minutes are distributed and otherwise made
available to members.
 Governing body meetings
 Substantive committees
Minutes kept (Yes/No)
How distributed to members (List all
ways)
Standard III--C
The pool conducts educational programs for
members on the topics listed below and provides
incentives to encourage member participation in
such activities.
 Safety/Risk management
 Other such appropriate topics
Date last educational
program was conducted
How did you encourage member
participation?
Standard III--D
The pool provides and supports risk management
and loss prevention practices among members.
How else do you support risk management and loss prevention practices
among members?
Standard III--E
The pool conducts regular loss prevention and
risk control surveys and/or inspections.
Date of last prevention and risk control survey and/or inspection
Standard III--F
If property coverage is provided, the pool
maintains accurate records of member property
values.
Cite policy – or section of policy – fulfilling standard, or how standard is
met:
IV. COVERAGES
This AGRiP Advisory Standard relates to policy coverage for the pool’s coverage document, specific excess insurance,
aggregate or stop-loss insurance, reinsurance and other catastrophic coverage obtained externally by the pool.
Standards addressed:
IV-A The pool regularly reviews insurance market trends, competition, coverage and pricing. Describe the frequency of
such reviews.
IV -B The pool has written, objective underwriting and/or rating procedures that relate to the exposures covered and the
losses experienced by pool members.
IV -C The pool provides appropriate coverage documents to its members. Explain what is provided.
IV -D The pool communicates changes in coverage to its members. Describe how.
IV -E The pool has a resolution process for claims and coverage disputes with its members.
IV -F The pool provides certificates or other evidence of coverages to all members and others.
Page 8 of 20
Document1
Standard IV-A
The pool regularly reviews
insurance market trends,
competition, coverage and
pricing. Describe the
frequency of such reviews.
Explain how
standard is met:
Standard IV-B
The pool has written,
objective underwriting
and/or rating procedures
that relate to the exposures
covered and the losses
experienced by pool
members.
Cite policy – or section of policy –
fulfilling standard, or how standard is
met:
Standard IV-C
The pool provides
appropriate coverage
documents to its members.
Explain what is provided.
Explain how standard is
met:
How often are
they provided to
members
Pool does not
provide these
documents (if not,
why not?)
N/A to pool because:
Standard IV-D
The pool communicates
changes in coverage to its
members. Describe how
Explain how standard is
met:
How are
changes
communicated
Pool does not
communicate
changes (if not, why
not?)
N/A to pool because:
Standard IV-E
The pool has a
resolution process for
claims and coverage
disputes with its
members.
Cite policy – or section of policy –
fulfilling standard, or how standard is
met:
Pool does not have a
dispute resolution policy
(if not, why not?)
N/A to pool because:
Standard IV-F
The pool provides
certificates or other
evidence of coverages to all
members and others.
Explain how standard is met:
Pool does not provide
evidence of coverage (if
not, why not?)
N/A to pool because:
Page 9 of 20
Frequency pool
does this
Document1
Date pool
last did this
Pool does not
do this (if not,
why not?)
Pool does not have this (if
not, why not?)
N/A to pool
because:
N/A to pool because:
V. FUNDING
The AGRiP Advisory Standards covering Funding address your policies and practices in the different aspects of reserve
adequacy and loss funding.
Standards addressed:
V-A
The pool has a policy requiring an Actuarial study to determine reserve adequacy is conducted and a report is issued
annually, signed by a Fellow of the Casualty Actuarial Society or a member of the American Academy of Actuaries,
independent of the pool. A biennial peer review of reserve adequacy by an actuary independent of the pool is
permissible under this Advisory Standard for pools employing an in-house actuary who issues a report annually and
is a Fellow of the Casualty Actuarial Society or a member of the American Academy of Actuaries.
V-B
The pool allocates funding for losses, loss development, incurred but not reported losses, allocated loss adjustment
expenses, unallocated loss adjustment expenses and adverse experience at a level set by the governing body based
on advice of a Fellow of the Casualty Actuarial Society or a member of the American Academy of Actuaries.
V-C
The pool has a strategy to deal with funding catastrophic losses to prevent financial impairment. Pool Board policy
contains a strategy for maintaining net assets to facilitate response to unanticipated events such as a change in
market conditions that force increased retentions, potential failure to pay by excess or reinsurers, loss of excess or
reinsurers, catastrophic events within retention or unusual claims not foreseen and not excluded.
V-D
If the pool purchases excess and/or reinsurance or uses other forms of risk transfer or risk sharing, it maintains files
of all related current and former binders, correspondence, policies, endorsements and certificates and makes copies
of such policies available to all members who so request.
V-E
If the pool purchases excess and/or reinsurance, the pool makes periodic evaluations of the quality, stability and
financial solvency of all insurance providers.
V-F
The pool insures or self-insures its administrative and operational risks, including errors and omissions, general and
auto liability, workers’ compensation, property, employee fidelity and fiduciary liability.
V-G
If the pool purchases insurance to cover its operational risk exposures, it maintains both current and historical files
of policies.
Standard V-A
The pool has a policy requiring an
Actuarial study to determine reserve
adequacy is conducted and a report is
issued annually, signed by a Fellow
of the Casualty Actuarial Society or a
member of the American Academy
of Actuaries, independent of the
pool. A biennial peer review of
reserve adequacy by an actuary
independent of the pool is
permissible under this Advisory
Standard for pools employing an inhouse actuary who issues a report
annually and is a Fellow of the
Casualty Actuarial Society or a
member of the American Academy
of Actuaries.
Cite policy
– or section
of policy –
fulfilling
standard,
or how
standard is
met:
Standard V-B
The pool allocates funding at
a level set by the governing body
based on advice of a Fellow of the
Casualty Actuarial Society or a
member of the American Academy
of Actuaries for:
1. Losses
2. Loss development
3. Incurred but not reported
losses
4. Allocated loss adjustment
Cite policy – or section of policy – fulfilling standard, or
how standard is met:
Page 10 of 20
Name of
Actuary
Document1
Is the
Actuary
Independent
or In-House?
List the
Actuaries
Credentials
What is the
date of the
most recent
reserve
study?
N/A to pool
because:
N/A to pool because:
5.
6.
expenses
Unallocated loss adjustment
expenses
Adverse experience
Standard V-C
The pool has:
1. A strategy to deal with
funding catastrophic losses
to prevent financial
impairment.
2. A pool Board policy that
contains a strategy for
maintaining net assets to
facilitate response to
unanticipated events such as
a change in market
conditions that force
increased retentions,
potential failure to pay by
excess or reinsurers, loss of
excess or reinsurers,
catastrophic events within
retention or unusual claims
not foreseen and not
excluded.
Cite policy – or section of policy – fulfilling standard, or
how standard is met:
Standard V-D
If the pool purchases excess and/or
reinsurance or uses other forms of
risk transfer or risk sharing, it
maintains files of all related current
and former binders, correspondence,
policies, endorsements and
certificates and makes copies of such
policies available to all members
who so request.
Explain how standard is met:
N/A to pool because:
Standard V-E
If the pool purchases excess and/or
reinsurance, the pool makes periodic
evaluations of the quality, stability
and financial solvency of all
insurance providers.
Explain how standard is met:
N/A to pool because:
Standard V-F
The pool insures or self-insures its
administrative and operational risks,
including:
Errors and Omissions
General and Auto Liability
Workers’ Compensation
Property
Employee Fidelity
Fiduciary Liability
Explain how standard is met:
N/A to pool because:
Page 11 of 20
Document1
N/A to pool because:
Standard V-G
If the pool purchases insurance to
cover its operational risk exposures,
it maintains both current and
historical files of policies.
Explain how standard is met:
N/A to pool because:
VI. FINANCIAL MANAGEMENT
The AGRiP Advisory Standards covering Financial Management recognize the vital role that management of financial
resources play in the vibrancy of a pool.
Standards addressed:
VI-A The governing body of the pool adopts an annual budget in sufficient detail so as to facilitate meaningful monitoring
of expenditures by the board or designated committee. The governing board or its designated committee reviews
budget to actual expenditures detail reports regularly to assure expenditures are appropriate.
VI-B
The pool has a written policy that addresses preparation of pool financial statements in accordance with generally
accepted accounting principles as applied to pools or as required by state law.
VI-C
The pool's accounting policy addresses adherence to accounting standards promulgated by the Governmental
Accounting Standards Board, the Financial Accounting Standards Board, and/or any applicable state regulatory
body.
VI-D
The pool board meeting minutes document the nature of financial reviews conducted by the board and any action
taken.
VI-E
The board (or its independent audit committee) appoints the audit firm that directly reports its findings to the board
or audit committee.
VI-F
An annual audit of the pool's financial records is conducted by a qualified independent certified public accountant or
state audit agency that issues a signed opinion regarding the financial statements.
VI-G
The audit includes an independent auditor's report on internal controls that provides a report on the status of
previous year’s recommended actions which is distributed to the board.
VI-H
The pool responds to any reportable conditions in the audit report on internal controls within a reasonable period of
time.
VI-I
Financial reports of the pool are distributed to or otherwise made available to the board, audit committee and pool
members at least annually.
VI-J
INVESTMENT POLICIES
VI-J-1. The pool has written policies that provide for annual review of the pool's investment policies by the
governing body.
VI-J-2. The pool has written policies that address explicit delegation of authority regarding investment decisions to
appropriate employees or outside investment managers.
VI-J-3. The pool has written investment policies that provide for appropriate controls, including those that address
separation of duties, safekeeping and custodial procedures.
VI-J-4. The pool has written policies that provide for a process to monitor its investment activities.
VI-J-5. The pool has written policies that address allocation of assets and portfolio diversification consistent with
state and federal regulations and prudent investment practices.
VI-J-6. The pool has written policies that provide for periodic reviews of investment results and comparisons with
set goals and external indices.
VI-J-7. The pool has written policies that provide for distribution of reports of investment activities to the pool's
governing body at least quarterly.
VI-J-8. The pool has written policies that address allocation of risk assets (investment securities without a stated
maturity, such as: stocks, equities, mutual funds, etc. other than fixed income) to surplus as a measure of solvency.
Page 12 of 20
Document1
STANDARD
Cite policy – or section of policy – fulfilling
standard, or how standard is met:
VI-A The governing body of the pool adopts
an annual budget in sufficient detail so as to
facilitate meaningful monitoring of
expenditures by the board or designated
committee. The governing board or its
designated committee reviews budget to actual
expenditures detail reports regularly to assure
expenditures are appropriate.
VI-B
The pool has a written policy that
addresses preparation of pool financial
statements in accordance with generally
accepted accounting principles as applied to
pools or as required by state law.
VI-C The pool's accounting policy
addresses adherence to accounting standards
promulgated by the Governmental Accounting
Standards Board, the Financial Accounting
Standards Board, and/or any applicable state
regulatory body.
VI-D The pool board meeting minutes
document the nature of financial reviews
conducted by the board and any action taken.
VI-E
The board (or its independent audit
committee) appoints the audit firm that directly
reports its findings to the board or audit
committee.
VI-F. An annual audit of the pool's financial
records is conducted by a qualified independent
certified public accountant or state audit agency
that issues a signed opinion regarding the
financial statements. Please include the date the
last audit was accepted by the board.
VI-G. The audit includes an independent
auditor's report on internal controls that
provides a report on the status of previous
year’s recommended actions which is
distributed to the board.
VI-H. The pool responds to any reportable
conditions in the audit report on internal
controls within a reasonable period of time.
VI-I.
Financial reports of the pool are
distributed to or otherwise made available to
the board, audit committee and pool members
at least annually.
Page 13 of 20
Document1
N/A to pool because:
VI-J. INVESTMENT POLICIES:
 VI-J-1. The pool has written policies that
provide for annual review of the pool's
investment policies by the governing body.







VI-J-2. The pool has written policies that
address explicit delegation of authority
regarding investment decisions to
appropriate employees or outside
investment managers.
VI-J-3. The pool has written investment
policies that provide for appropriate
controls, including those that address
separation of duties, safekeeping and
custodial procedures.
VI-J-4. The pool has written policies that
provide for a process to monitor its
investment activities.
VI-J-5. The pool has written policies that
address allocation of assets and portfolio
diversification consistent with state and
federal regulations and prudent investment
practices.
VI-J-6. The pool has written policies that
provide for periodic reviews of investment
results and comparisons with set goals and
external indices.
VI-J-7. The pool has written policies that
provide for distribution of reports of
investment activities to the pool's
governing body at least quarterly.
VI-J-8. The pool has written policies that
address allocation of risk assets
(investment securities without a stated
maturity, such as: stocks, equities, mutual
funds, etc. other than fixed income) to
surplus as a measure of solvency.
VII. BUSINESS CONTINUITY
The AGRiP Advisory Standards covering Business Continuity recognize the need for adequate written policies and
procedures in dealing with threats to the ongoing operations of the organization.
Standards addressed:
VII-A The pool has developed and implemented processes and procedures relating to protection of electronic files. Data
includes, but is not limited to, internal electronic data storage regardless of storage format or media and data that is
transmitted outside the pool via websites, email, etc. The policy addresses security, back-up systems, data retention,
encryption and disaster recovery.
VII-B The pool has adopted an asset inventory and control policy.
VII-C The pool has adopted a records management policy.
Page 14 of 20
Document1
STANDARD
Cite policy – or section of policy – fulfilling
standard, or how standard is met:
N/A to pool because:
VII-A The pool has developed and
implemented processes and procedures relating
to protection of electronic files. Data includes,
but is not limited to, internal electronic data
storage regardless of storage format or media
and data that is transmitted outside the pool via
websites, email, etc. The policy addresses:
 Security/Encryption
 Back-up systems
 Data retention
 Disaster recovery
VII-B The pool has adopted an asset
inventory and control policy.
VII-C The pool has adopted a records
management policy.
VIII. CLAIMS MANAGEMENT
The AGRiP Advisory Standards covering Claims Management recognize the need for adequate written policies and
procedures in administering claims against members.
Standards addressed:
VIII-A The pool has written procedures that include settlement authority structure, internal review/audit procedures, and
loss reserving.
VIII -B The pool maintains a comprehensive claims management information system and/or accounting system that tracks
claims, develops loss data, and is distributed to members on a regular basis.
VIII -C The pool maintains a litigation management program that includes, but is not limited to, establishment of a list of
qualified attorneys when applicable, establishment of reporting procedures, and ongoing monitoring and case
management, including evaluation of legal expenses.
VIII -D THE CLAIMS AUDIT:
VIII -D-1
In addition to the tests conducted during the course of a financial audit a claims audit is
conducted at least once every three years regardless of whether claims are handled by inhouse staff or by an outside service provider.
VIII -D-2
The claims audit includes determination that claims were handled in a timely and
efficient manner.
VIII -D-3
The claims audit includes determination that the claims administrator adequately
communicated.
VIII-D-4
The claims audit includes determination that case reserving practices were reasonable.
VIII -D-5
The claims audit includes determination that loss experience reports accurately reflect
case reserves and payments.
VIII -D-6
The claims audit is conducted by a qualified firm or individual engaged by the pool that
is independent of the pool and its claims service providers.
VIII -D-7
The claims auditor issues a report on the condition of the pool's claims handling and
reserving practices noting significant exceptions and/or deficiencies.
VIII -D-8
The pool adequately addresses all exceptions or deficiencies noted in the claims audit
within a reasonable period of time.
STANDARD
Cite policy – or section of policy – fulfilling
N/A to pool because:
standard, or how standard is met:
VIII-A The pool has written procedures that
include:
 Settlement authority structure
 Internal review/audit procedures
 Loss reserving
Page 15 of 20
Document1
STANDARD
VIII -B The pool maintains a comprehensive
claims management information system and/or
accounting system that:
 Tracks claims
 Develops loss data
 Is distributed to members on a regular
basis
Explain how standard is met:
N/A to pool because:
STANDARD
VIII -C The pool maintains a litigation
management program that includes, but is not
limited to:
 Establishment of a list of qualified
defense attorneys when applicable
 Establishment of reporting procedures
 Ongoing monitoring and case
management, including evaluation of
legal expenses
Explain how standard is met:
N/A to pool because:
Cite policy – or section of policy – fulfilling
standard, or how standard is met:
N/A to pool because:
Explain how standard is met:
N/A to pool because:
STANDARD VIII -D: The Claims Audit
VIII -D-1
In addition to the tests
conducted during the course of a financial audit
a claims audit is conducted at least once every
three years regardless of whether claims are
handled by in-house staff or by an outside
service provider. Please include the date of the
last claims audit.
VIII -D-2 The claims audit includes
determination that claims were handled in a
timely and efficient manner.
VIII -D-3 The claims audit includes
determination that the claims administrator
adequately communicated
VIII -D-4 The claims audit includes
determination that case reserving practices
were reasonable.
VIII -D-5 The claims audit includes
determination that loss experience reports
accurately reflect case reserves and payments.
VIII -D-6 The claims audit is conducted by a
qualified firm or individual engaged by the
pool that is independent of the pool and its
claims service providers.
VIII -D-7 The claims auditor issues a report on
the condition of the pool's claims handling and
reserving practices noting significant
exceptions and/or deficiencies.
VIII -D-8 The pool adequately addresses all
exceptions or deficiencies noted in the claims
audit within a reasonable period of time.
Page 16 of 20
Document1
IX. PROFESSIONAL DEVELOPMENT
The AGRiP Advisory Standards for Professional Development recognize the value of continuing education.
Standards addressed:
IX-A Members of the governing body of the pool participate in relevant professional conferences and seminars presented
by organizations other than the pool.
IX-B
Pool staff participates in relevant professional development programs.
IX-C
The pool chief executive officer regularly attends relevant state and national professional conferences and seminars.
IX-D
Pool staff members obtain educational degrees, relevant professional designations and other certifications.
IX-E
Pool staff members participate in relevant professional organizations.
IX-F
The pool provides adequate funding to support professional development.
STANDARD
List meetings normally attended and/or meeting
most recently attended
N/A to pool because:
Standard IX-D
Pool staff members obtain educational degrees,
relevant professional designations and other
certifications.
List degrees or designations currently held by
staff. Identify programs in process in which pool
staff are participating.
N/A to pool because:
Standard IX-E
Pool staff members participate in relevant
professional organizations.
List organizations and level of staff
participation.
N/A to pool because:
Standard IX-F
The pool provides adequate funding to support
professional development.
Explain how standard is met:
N/A to pool because:
IX-A Members of the governing body of the
pool participate in relevant professional
conferences and seminars presented by
organizations other than the pool.
IX-B Pool staff participates in relevant
professional development programs.
IX-C The pool chief executive officer regularly
attends relevant state and national professional
conferences and seminars.
X. GOVERNANCE
The AGRiP Advisory Standards for Organizational Planning recognize the value of long-range or strategic planning.
Standards addressed:
X-A
The pool governing board assures that its members receive a regular orientation program and manual for new and
returning board members that includes review of the organizational governance structure, operations, legal and
fiduciary responsibilities, budget and accounting system, actuarial funding, financial and investment policies.
X-B
The pool develops and maintains a long-range or strategic plan that contains a mission statement and clearly defined
goals and objectives.
X-C
The pool regularly reviews and revises its long-range or strategic plan.
X-D
The pool regularly develops a short-term or operational work plan based on its long-range or strategic plan.
X-E
The pool's governing body and staff regularly review the work plan to ensure that activities are completed and goals
and objectives are met.
X-F
The governing body has a policy in regard to how they are to receive reports on/or from executive staff,
key functional areas and service providers.
Page 17 of 20
Document1
STANDARD
X-A
The pool governing board assures that
its members receive a regular orientation
program and manual for new and returning
board members that includes:
 Review of the organizational
governance structure.
 Operations.
 Legal and fiduciary responsibilities.
 Budget and accounting system.
 Actuarial funding.
 Financial and investment policies.
STANDARD
Explain how standard is met:
N/A to pool because:
Explain how standard is met:
Date of last
review/development
N/A to pool
because:
Cite policy – or section of policy
– fulfilling standard, or how
standard is met:
Date of last
review/development
N/A to pool
because:
X-B
The pool develops and maintains a
long-range or strategic plan that contains a
mission statement and clearly defined goals
and objectives.
X-C
The pool regularly reviews and
revises its long-range or strategic plan.
X-D
The pool regularly develops a shortterm or operational work plan based on its
long-range or strategic plan.
X-E
The pool's governing body and staff
regularly review the work plan to ensure that
activities are completed and goals and
objectives are met.
X-F
The governing body has a
policy in regard to how it is to
receive reports on/or from executive
staff, key functional areas and service
providers.
XI. ETHICS
The AGRiP Advisory Standards covering Ethics policies recognize that members of public entity pools are public organizations,
such as schools and transit districts, and that public entity pools are governed by boards made up of public officials. Thus,
adherence to a defined policy, such as the AGRiP model policies, encourages public trust and proper decision--making within the
pool. A model Code of Conduct and a Pool Service Providers’ Bill of Rights adopted by the AGRiP Board of Directors are
available to download on the AGRiP web site.
Standards addressed:
XI-A The pool has a Code of Conduct applicable to the pool governing body, staff (whether directly employed
by the pool or under contract) and service providers that is generally consistent with the AGRiP Model Code of Conduct.
Page 18 of 20
Document1
Standard XI-A
The pool has a Code
of Conduct
applicable to the
pool governing
body, staff (whether
directly employed
by the pool or under
contract) and service
providers that is
generally consistent
with the AGRiP
Model Code of
Conduct.
Cite policy – or section of
policy – fulfilling
standard, or how
standard is met:
Date
Adopted
No, pool
does not
have
N/A to
pool
If No or N/A, explain
Governing
Body
Staff
Service
Providers
Optional Feedback
To help us improve operations, please provide any comments on the application and/or application process
below:
Page 19 of 20
Document1
Attestation of Agreement
Recipients of the Advisory Standards Recognition sponsored by the Association of Governmental Risk Pools acknowledge
and agree that the program was developed to encourage and promote compliance with recognized Standards. Recognition, if
provided, acknowledges that the recipient's self-evaluation demonstrates general compliance with the recommended
operational practices and documentation.
Recipients further acknowledge and agree that the Advisory Standards and Recognition are intended to be a benchmark to
measure and guide, but do not attest to the solvency nor define the capacity, content or quality of organizational and
operational characteristics of public entity risk and employee benefit pools. AGRiP has not and does not intend to undertake
an audit or independent verification review to confirm the truth or accuracy of the Recipient's assertions.
Recipients of the Advisory Standards Recognition agree not to use the Recognition in any way that implies or suggests that
through the Recognition AGRiP guarantees that the pool is appropriately managed or financially solvent.
The following Verification section is completed and agreed to by the pool and a certified copy of a Board Resolution or
excerpt from the minutes of the Board meeting is attached to evidence that this self-evaluation form has been approved.
Verification
Name of Pool
Name and Title of Contact Person
Street Address
City
State
Telephone
Zip Code
Fax
Date of Completion
This evaluation was conducted by
(Name of Committee or Person and Title)
This evaluation was reviewed and approved by the executive committee or board of directors/trustees:
Signature
Name
Title
(Chair of the Board or Executive Committee)
NOTE TO APPLICANTS: Evaluations forms will not be accepted unless they are:
1. Fully completed
2. Signed by the chairperson of the executive committee or the board of directors
3. Accompanied by the application fee in the amount of $600
4. Submitted with a certified copy of a Board resolution or excerpt from minutes evidencing the Board's approval of
the contents of the application.
Page 20 of 20
Document1