Employers Application For The Privilege Of Paying Compensation As Self Insurer {WC 2005}

CONFIDENTIAL LOUISIANA OFFICE OF WORKERS' COMPENSATION ADMINISTRATION POST OFFICE BOX 94040 BATON ROUGE, LOUISIANA 70804-9040 EMPLOYERS APPLICATION FOR THE PRIVILEGE OF PAYING COMPENSATION PROVIDED IN THE LOUISIANA WORKERS' COMPENSATION ACT AS SELF-INSURER To the Louisiana Office of Workers' Compensation Administration: The undersigned, an employer subject to the provisions of the Louisiana Workers' Compensation Act, hereby applies for the privilege of becoming a self-insurer for the payment of compensation provided in that Act, and submits the following facts, under oath, to the Louisiana Office of Workers' Compensation Administration to enable it to determine if sufficient financial ability exists to render certain the payment of such compensation: 1. Name of applicant 2. Address (Number) 3. The applicant is (State whether individual, co-partnership, limited partnership, corporation, receiver or trustee) 4. Describe briefly the general character of the operations performed and the articles manufactured or compounded at or away from the plant or premises of the applicant. (Street) (City or Town) (Parish) (State) (Zip) 5. Description of employment for ensuring year: Location of Plant or Plants Kind of Employment Estimated Average No. of Employees at all points Estimated Average No. of Employees- Louisiana Est. Payroll of all Employees Please attach sheet if you require additional space 6. If a corporation or limited partnership, list below names of officers, directors, and residence of each: LWC-WC-2005 American LegalNet, Inc. www.FormsWorkflow.com If a partnership, list below names of members and residence of each Sole Owner Residence 7. Very Important: You are required to provide financial statements for the latest three year period. Provide details of any material contingent liabilities not included in the most recent financial statements. Provide details of any customer notes or accounts receivable that have been discounted or sold and not reflected in the most current financial statements. 8. Is the applicant a subsidiary? If so, give name and address of parent company. 9. Relate facts, covering the past three years: Year Year 19 Year 19 Year 20 Amounts of indebtedness past due Insurance on merchandise Insurance on building and plants $ $ $ Sales Expenses (Including) Pay Roll Pay Roll Profits 10. Safety, sanitation and welfare conditions: Is your plant inspected otherwise than by State authority? If so, by whom? Have you fulfilled all safety requirements of the LA Workforce Commission? 11. Past accident experience: Year 19__ Number of deaths Number of dismemberments Number of accidents of all kinds Year 19 Year 20 __ (Continued on Next Page) American LegalNet, Inc. www.FormsWorkflow.com In addition to the above summary loss data, all applicants are required to submit their complete latest three years detailed workers' compensation loss data. The guidelines for the loss data report are detailed in Title 40, Chapter 17, Section 1711 of our Fiscal Responsibility Unit Rules. 12. In consideration of the approval of this application, the applicant hereby expressly agrees as follows: (a) that this privilege may be revoked at any time in the discretion of the Louisiana Office of Workers' Compensation Administration, as provided in Section 1291 (B)(7) of the Act. (b) That the applicant will fully discharge by cash payments all liabilities that may arise under Title 23, Chapter 10 of the Louisiana Revised Statutes of 1950 and known as the Louisiana Workers' Compensation Act. (c) The applicant agrees to deposit with the Louisiana Office of Workers' Compensation, as directed by the Office, acceptable security or indemnity bond to secure payment of compensation liabilities in the amount and manner as directed by Office. (d) This applicant agrees to pay to the Louisiana Office of Workers' Compensation Administration the Administrative and Second Injury Fund Assessments and the initial fee of $100 as required by law. (Signature of Applicant) By (Official & Title) State of Parish (County) of , being first duly sworn, appeared personally and declared that the facts set forth in the foregoing application are true to the best of his knowledge, information and belief. Subscribed and sworn to before me the day of , 20 . (SEAL) My Commission expires on the day of 20 (This affidavit may be sworn to before any person authorized to administer an oath) . IMPORTANT When the applicant is a subsidiary company or a partnership, the Office may require that the Parent company, or any other company or persons holding stock in the applicant company, or a partner or partners in the applicant partnership, shall give satisfaction guarantee that the applicant will fully and promptly pay all sums which are or may become payable under the provisions of the Louisiana Workers' Compensation Act and under the terms of the agreement contained in his application. American LegalNet, Inc. www.FormsWorkflow.com