Standard Coverage Form - Group Self Insurance Fund Members {WC-11}

WC-11 STANDARD COVERAGE FORM GEORGIA STATE BOARD OF WORKERS' COMPENSATION STANDARD COVERAGE FORM GROUP SELF-INSURANCE FUND MEMBERS PLEASE TYPE DETAILED INSTRUCTIONS GIVEN ON BACK OF FORM A. INFORMATION ABOUT THE FUND MEMBER FILE SEPARATELY FOR EACH UPDATE 1. Insured Member 2. Member Address 5. dba (Doing Business As, if applicable) 6. New dba or New Location Address 3. Type of Business 4. EFFECTIVE DATE (Original Effective Date of Fund Member) 7. Franchise/Store # (if applicable) 8. Policy Number B. CHANGES TO ORIGINAL POLICY / ACTION REQUIRED New dba Name Effective Date 1. ADD New Location Address Effective Date 2. ADD Member Name Listed in Section A Effective Date 3. CANCEL dba Name Listed in Section A Effective Date 4. CANCEL Location Listed in Section A Effective Date 5. CANCEL Name(s) in Section A Effective Date 6. REINSTATE NAME CHANGE (New Name Should Appear in Section A) Member Name Effective Date 7. Old dba Name Effective Date 8. ADDRESS CHANGE (New Address Should Appear in Section A) Member Address 9. Old dba Address or Location Address 10. C. INFORMATION ABOUT THE GROUP FUND AND SERVICING AGENT Group Self-insurance Fund Name SBWC ID# (five digit no.) 1. Name and Address of Servicing Agent 2. Name (of Person Completing Form) Phone and Ext. 3. IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS' COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. §34-9-18 AND §34-9-19). WC-11 REVISION . 07/2012 11 1 OF 2 STANDARD COVERAGE FORM American LegalNet, Inc. www.FormsWorkFlow.com WC-11 STANDARD COVERAGE FORM GEORGIA STATE BOARD OF WORKERS' COMPENSATION Use form WC-11 to: To notify Board of coverage of new fund member, complete Sections A and C. To notify Board of changes/activity, (as listed in Section B) complete A, B, and C. Mail to: Coverage Section State Board of Workers' Compensation 270 Peachtree Street, NW Atlanta, GA 30303-1299 404-656-3692 INSTRUCTIONS FOR COMPLETING FORM WC-11 SECTION A: 1. 2. 3. 4. 5. 6. 7. 8. ENTER COMPLETE MEMBER NAME (IF NAME HAS CHANGED, PUT NEW NAME HERE). ENTER ADDRESS OF MEMBER OFFICE (IF ADDRESS HAS CHANGED, PUT NEW ADDRESS HERE). ENTER TYPE OF BUSINESS (I.E. general contractor, retail sales, restaurant, landscaping, etc.). ENTER ORIGINAL EFFECTIVE DATE OF INSURED MEMBER. ENTER DOING BUSINESS AS (dba) NAME WHEN DIFFERENT FROM MEMBER NAME. COMPLETE SEPARATE FORM WC-11 FOR EACH DIFFERENT (dba) NAME. ENTER ADDRESS OF (dba) LOCATION (IF MORE THAN ONE LOCATION, USE SEPARATE FORM WC-11). ENTER HERE IF A FRANCHISE OR "CHAIN" USES A STORE NUMBER TO IDENTIFY A SPECIFIC LOCATION. ENTER POLICY NUMBER ISSUED WHEN INSURANCE IS PURCHASED. SECTION B: CHECK EXACT ACTION(s) BEING TAKEN AND GIVE EFFECTIVE DATE OF ACTION. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. ADD DOING BUSINESS AS (dba) NAME AS SHOWN IN SECTION A - (5). ADD LOCATION ADDRESS AS SHOWN IN SECTION A - (6). CANCEL MEMBER NAME AS IN SECTION A - (1). CANCEL DOING BUSINESS AS (dba) NAME AS SHOWN IN SECTION A - (5). CANCEL LOCATION ADDRESS AS SHOWN IN SECTION A - (6). EFFECTIVE DATE OF REINSTATEMENT. MEMBER NAME PRIOR TO NAME CHANGE. DOING BUSINESS AS (dba) NAME PRIOR TO NAME CHANGE. OLD MEMBER ADDRESS PRIOR TO ADDRESS CHANGE. OLD DOING BUSINESS AS (dba) ADDRESS PRIOR TO ADDRESS CHANGE. SECTION C: 1. 2. 3. COMPLETE GROUP SELF-INSURANCE FUND NAME - DO NOT USE ABBREVIATIONS OR INITIALS. NAME AND ADDRESS OF THIRD PARTY ADMINISTRATOR PROCESSING CLAIMS. NAME AND PHONE NUMBER (WITH EXTENSION) OF PERSON COMPLETING FORM - DO NOT USE INITIALS. IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS' COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. §34-9-18 AND §34-9-19). WC-11 REVISION . 07/2012 11 2 OF 2 STANDARD COVERAGE FORM American LegalNet, Inc. www.FormsWorkFlow.com