Service Company Application {WC 2007}

Kathleen Babineaux Blanco John Warner Smith Governor Secretary CONFIDENTIAL THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE WORKER'S COMPENSATION ACT. LOUISIANA OFFICE OF WORKERS' COMPENSATION POST OFFICE BOX 94040 BATON ROUGE, LA 70804-9040 PHONE (225) 342-5658 FAX (225) 342-7578 SERVICE COMPANY APPLICATION 1. Name of Applicant 2. Applicant status Corporation ( ), Partnership ( ), Individual ( ) 3. Address of Home Office 4. Address of Louisiana Office 5. Names and Addresses of Owners, Partners or Corporate Officers 6. Name and Address of Resident Claim Agent 7. Include summary data and resumes of your personnel in accordance with Sec. 1715 (c). LWC-WC-2007 Office of Workers' Compensation 1001 North 23rd Street Post Office Box 94040 Baton Rouge, LA 70804-9040 PHONE 225-342-7561 FAX 225-342-5665 www.LAWORKS.net American LegalNet, Inc. www.FormsWorkflow.com Page 2 We certify that the information submitted with this application is true and correct to the best of our knowledge. Further, we agree to update any change in our personnel or report any data material to this application to this office as the need may arise. (applicant) By (official and title) State of Parish or County of Subscribed and sworn to me by on this day of 20 (SEAL) (Notary Public) My Commission Expires: American LegalNet, Inc. www.FormsWorkflow.com