Application To Individually Self-Insure {7}

South Carolina Workers' Compensation Commission SELF-INSURANCE DIVISION 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5706 Page 1 of 3 APPLICATION TO INDIVIDUALLY SELF-INSURE 1. 2. 3. 4. 5. Name: Address: Telephone Number: Employer's Federal Identification Number: Applicant is a (check one): (A) Corporation (B) Partnership (C) Sole Proprietorship (D) Subsidiary Corporation (whose parent is self-insured or applying to self-insure in this state) (E) Other (Attach Explanation) 6. Are you now self-insured for workers' compensation in other states? If yes, list states and effective dates: 7. Do you have applications to self-insure pending in other states? If yes, list states: 8. In the most recent fiscal year what was your workers' compensation premium and experience modification for South Carolina? Yes No Yes No Applicant's SIC Code: ( ) - Premium Amount: Experience Modification: 9. Name of Present Carrier: Provide employment information for the current year for each business location in South Carolina (provide attachment if necessary): Locations in South Carolina Number of Employees in South Carolina Estimated Payroll for South Carolina Total: 10. Total number of employees company-wide: For further information, refer to Article 15 of the South Carolina Workers' Compensation Commission's Regulations. WCC Form # 7 Created 3/96 7 APPLICATION TO INDIVIDUALLY SELF-INSURE American LegalNet, Inc. www.FormsWorkFlow.com South Carolina Workers' Compensation Commission SELF-INSURANCE DIVISION 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5706 Page 2 of 3 11. If a corporation or limited partnership list the names of officers, directors, and residence of each. If a partnership, list the names of members and residence of each. 12. If a corporation: Date of charter years. and State charter was obtained 13. Provide the following information for workers' compensation claims information for South Carolina for the three most recent Year Number of Claims Amount Paid Medical Indemnity Total Medical Amount Incurred Indemnity Total 14. Name, title, address and telephone number for contact person for claims administration: 15. Name, title, address and telephone number for contact person for self-insurance tax and financial issues: The undersigned, an employer subject to the provisions of the South Carolina Workers' Compensation Law, hereby applies for the privilege of being exempt from the necessity of insuring the payment of compensation provided in that Law, and submits the following facts under oath to the South Carolina Workers' Compensation Commission to enable it to determine if sufficient financial ability exists to render certain payment of such compensation: Reserved for Commission Use Only Approved: _________________ Effective Date: ________________ SI No. _________________ For further information, refer to Article 15 of the South Carolina Workers' Compensation Commission's Regulations. WCC Form # 7 Created 3/96 7 APPLICATION TO INDIVIDUALLY SELF-INSURE American LegalNet, Inc. www.FormsWorkFlow.com South Carolina Workers' Compensation Commission SELF-INSURANCE DIVISION 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5706 Page 3 of 3 By: Applicant's Name: Signature: ______________________________________________________________________________________ Sworn and subscribed before me this ______ day of _____________ year _____________ Notary Public for: _______________________________________________________________________________ My commission expires: __________________________________________________________________________ Attach the following: 1. $250 application fee, $100 for each subsidiary. 2. Description of the business, including operations and articles manufactured or services performed. 3. Description of your safety program. 4. Three years audited financial statements or Form 10K's and most recent quarterly report. 5. Excess insurance quotes for South Carolina. 6. Name of carrier or bank providing the required surety bond or irrevocable letter of credit. 7. Statement describing proposed claims administration. Include a copy of claims service agreement. If handling claims in-house provide resumes of claims staff and licensed adjuster(s). When the applicant is a subsidiary company or a partnership, the Commission requires that the parent company, or any other company or person holding stock in the applicant company, or a partner or partners in the partnership, shall give satisfactory guarantee that the applicant will full and promptly pay all sums which are or may become payable under the provisions of the South Carolina Workers' Compensation Law and under the terms of the agreement contained in this application. For further information, refer to Article 15 of the South Carolina Workers' Compensation Commission's Regulations. WCC Form # 7 Created 3/96 7 APPLICATION TO INDIVIDUALLY SELF-INSURE American LegalNet, Inc. www.FormsWorkFlow.com