Employer Participation Form

State of Connecticut Workers' Compensation Commission Workers' Compensation Medical Care Plan Employer Participation Form Plan Sponsor Name of Employer Subsidiary or D/B/A (circle one) Business Location(s) Nature of Business Total Number of Employees If more than one business location, attach addresses and number of employees at each site. Name and Title of Employer Representative Phone ( ) - Signature of Employer Representative Current Workers' Compensation Carrier (please indicate if authorized self-insurer) Policy No. Claims Office Location Policy Term American LegalNet, Inc. www.FormsWorkFlow.com Plan Participation 1. Are any of your employees covered by a collective bargaining agreement? Yes No If YES, include a statement that the Employer's participation is not in violation of any collective bargaining agreement, a copy of which will be made available to the Chairman upon request. 2. Has the Employer agreed to the performance of all obligations as outlined in the original Plan Application? Yes No If NO, please attach a detailed description of any Employer responsibilities which have been amended by a client-sponsor contract. 3. Attach a copy of Approved Health & Safety Committee Certificate (employers of 25 or more). 4. Attach a description of the financial arrangements between Plan and Employer (CONFIDENTIAL). 5. Attach a copy of the plain language explanation to be distributed to employees. 6. Attach a description of the Modified/Light Duty Work Program (employers of 50 or more). American LegalNet, Inc. www.FormsWorkFlow.com