Free 81-AI.qxd - Missouri

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS COMPENSATION

APPLICATION FOR AUTHORITY TO SELF-INSURE

P.O. BOX 58 3315 W. TRUMAN BLVD. JEFFERSON CITY, MO 65102-0058

(TO BE EXECUTED AND SWORN TO IN TRIPLICATE) ALL INFORMATION CALLED FOR ON APPLICATION MUST BE IN TYPEWRITTEN FORM The undersigned (thereinafter referred to as the Applicant) hereby makes application to carry his/its own liability without insurance as provided in the Missouri Workers Compensation Law. In connection with such application he/it makes the following declaration for the purpose of enabling the Division of Workers Compensation to determine whether he/it possesses sufficient financial ability to render certain the payment of compensation which his/its employees and their dependents may be entitled to under the Missouri Workers Compensation Law. Applicant hereby agrees that if this application be approved, such approval shall be subject to his/its furnishing such security as may be required by the Division of Workers Compensation. Applicant further agrees to abide by all of the provisions of the Missouri Workers Compensation Law and by the rules governing self-insurers under said law.
1. NAME OF APPLICANT (IF A CORPORATION IS ORGANIZED UNDER THE LAWS OF A STATE 3. NATURE OF BUSINESS OTHER THAN MISSOURI, A CERTIFIED COPY OF CERTIFICATE OF AUTHORITY TO DO A. DESCRIBE BRIEFLY THE GENERAL CHARACTER OF THE OPERATIONS PERFORMED BUSINESS IN MISSOURI SHOULD ACCOMPANY THE APPLICATION.) AND THE ARTICLES MANUFACTURED OR COMPOUNDED AT THE PLANT OR ON THE PREMISES OF THE EMPLOYER.

_________________________________________________________________________________ _________________________________________________________________________________

_________________________________________________________________________________ _________________________________________________________________________________

2. ADDRESS (PRINCIPLE OFFICE)

CITY

STATE

ZIP CODE

B. DESCRIBE BRIEFLY ALL CLASSES OF WORK PERFORMED AWAY FROM THE EMPLOYERS PLANT OR PREMISES, INCLUDING THE DEMONSTRATION, IF ANY, OF THE EMPLOYERS PRODUCT AND ALL GENERAL OPERATIONS OF CONSTRUCTION, INSTALLATION OR EXCAVATION. _________________________________________________________________________________

TELEPHONE NUMBER _________________________________________________________________________________ ADDRESS (MISSOURI OFFICE) _________________________________________________________________________________ CITY STATE ZIP CODE _________________________________________________________________________________ TELEPHONE NUMBER

4. PARENT COMPANY NAME

5. PARENT COMPANY ADDRESS

6. STATE WHERE INCORPORATED

7. NAME AND ADDRESS OF EXCESS INSURANCE CARRIER

8. WHAT COMPANY NOW IS CARRYING YOUR COMPENSATION INSURANCE?

9. TOTAL WORKERS COMPENSATION PAID IN PAST YEAR?

INSURANCE MODIFICATION FACTOR

10. DESCRIBE FULLY IN AN ATTACHED STATEMENT THE SAFETY ORGANIZATION MAINTAINED WITHIN YOUR FIRM FOR THE PREVENTION OF ACCIDENTS AS WELL AS A DESCRIPTION OF THE ADMINISTRATIVE ORGANIZATION MAINTAINED TO HANDLE WORKERS COMPENSATION MATTERS. INCLUDE THE REPORTING OF INJURIES, AUTHORIZATION OF MEDICAL CARE, PAYMENT OF COMPENSATION, AND THE HANDLING OF CLAIMS FOR COMPENSATION, TOGETHER WITH THE NAME AND ADDRESS OF EACH SUCH OFFICE AND THE QUALIFICATIONS OF THE PERSONNEL IN EACH OFFICE TO PERFORM THIS SERVICE.

11. DATE YOU WISH AUTHORITY TO BECOME EFFECTIVE

WC-81 (8-99) AI

13. CLASSIFICATIONS AND PAYROLL IN MISSOURI
12. LOCATION OF FACTORIES, OFFICES, OR OTHER WORKPLACES IN STATE OF MISSOURI, AND NUMBER OF EMPLOYEES ENGAGED IN EACH PLACE.

PLANT LOCATION

NO. OF EMPLOYEES

(EXAMPLE) CLERICAL DRIVERS OUTSIDE SALES

CLASSIFICATION CODE NUMBER - IF KNOWN, & DESCRIPTION OF JOB

ESTIMATED PAYROLL OF AVERAGE EMPLOYEES FOR ONE YEAR - THE TWELVE MONTHS CLASS NUMBER PRECEDING DATE OF APPLICATION. THIS OF CODE PAYROLL SHALL INCLUDE EMPLOYEES ALL EMPLOYEES.

8810 7380 8742

TOTAL ......................................................

TOTAL .................................

GO TO PAGE 3: (REMAINDER OF THIS PAGE FOR DIVISION USE ONLY)

APPLICATION GRANTED ON CONDITION THAT THE APPLICANT FILE ESCROW AGREEMENT AND DEPOSIT SECURITIES OR CASH IN THE AMOUNT OF $____________________ OR PROVIDE SURETY BOND IN THE PRINCIPLE SUM OF $____________________. SELF-INSURANCE AUTHORITY WILL BECOME EFFECTIVE AS OF DATE APPROVED SECURITY, IN THE AMOUNT REQUIRED, IS FILED AT THE OFFICE OF THE DIVISION IN JEFFERSON CITY. ESCROW AGREEMENT FILED (DATE) __________________, SHOWING SECURITIES OR CASH IN THE AMOUNT OF $____________________ DEPOSITED IN ESCROW IN THE (NAME OF BANK) ________________________________________________________________________________________________________ OF (ADDRESS OF BANK) _______________________________________________________________________________________________________________________

SURETY BOND FOR

DATE EFFECTIVE

NAME OF SURETY COMPANY

$
AUTHORITY APPROVED: SIGNATURE (DIVISION OF WORKERS COMPENSATION)

SELF-INSURANCE AUTHORITY EFFECTIVE ON (DATE)

DATE

FINANCIAL STATEMENT
NOTE THE DIVISION REQUIRES THAT ALL ITEMS LISTED BELOW BE COMPLETED.
CONFIDENTIAL REPORT MADE TO THE DIVISION OF WORKERS COMPENSATION FOR THE PURPOSE OF SHOWING FINANCIAL ABILITY TO PAY COMPENSATION THIS _____________________________ DAY OF ____________________________________, __________. DATE FISCAL YEAR ENDS:
1. NAME 2. ADDRESS

ASSETS
3. CURRENT ASSETS CASH ON HAND AND ON DEPOSIT NOTES RECEIVABLE LESS NOTES RECEIVABLE DISCOUNTED ACCOUNTS RECEIVABLE LESS RESERVE FOR DOUBTFUL ACCOUNT INVENTORIES (ITEMIZED)

$ $ $ $ $

$ $ $ $ $

$
OTHER CURRENT ASSETS (ITEMIZED)

TOTAL CURRENT ASSETS 4. INVESTMENTS (DESCRIBE FULLY) (SECURITIES OF SUBSIDIARY OR AFFILIATED COMPANIES SHOULD BE LISTED SEPARATELY)

$

$
5. SINKING FUNDS AND OTHER FUNDS

$
6. FIXED ASSETS (DEPRECIATION RESERVES TO BE SHOWN SEPARATELY)

TOTAL FIXED ASSETS 7. DEFERRED CHANGES

$

$
8.

TOTAL ASSETS

$
WC-81-2 AI

LIABILITIES
9. CURRENT LIABILITIES - NOTES PAYABLE FOR MERCHANDISE FOR MONEY BORROWED ACCOUNTS PAYABLE OTHER CURRENT LIABILITIES (ITEMIZED)

$ $ $ $

$ $ $ $

TOTAL OTHER LIABILITIES TOTAL CURRENT LIABILITIES 10. FIXED LIABILITIES (DESCRIBE FULLY)

$ $

TOTAL FIXED LIABILITIES

$

NET WORTH
11. (IF A CORPORATION) CAPITAL STOCK, ISSUED AND OUTSTANDING

$
SURPLUS (AVAILABLE FOR DIVIDENDS)

$
SURPLUS RESERVES

$
(IF AN INDIVIDUAL OR PARTNERSHIP) CAPITAL UNDIVIDED PROFITS 12.

$ $
TOTAL LIABILITIES AND NET WORTH

$

13. NAME BANKS IN WHICH COMPANY HAS ACCOUNTS ___________________________________________________________________________________________ _______________________________________________________________________________________________________________________________ _________ 14. (A) INSURANCE ON INVENTORIES (B) INSURANCE ON PLANT 15. AMOUNT OF ANNUAL BUSINESS 17. WHEN INCORPORATED 19. DID YOU SUCCEED ANYONE o YES 20. PRESIDENT 21. TREASURER 16. NATURE OF BUSINESS UNDER LAWS OF WHAT STATE o NO (IF YES, WHOM) 22. VICE-PRESIDENT 23. SECRETARY 18. IF NOT A CORP., WHEN ESTABLISHED?

$ $

NAMES OF OFFICERS

_______________________________________, being duly sworn, says that he/she is the __________________________________________________ of the above-named applicant for leave to pay compensation for its/his/her self, pursuant to the Missouri Workers Compensation Law; that he/she has carefully examined the foregoing statement and the facts therein set forth are true; that the applicants assets are correctly set forth and there are no other liabilities against the applicant than those set forth therein.
__________________________________________________________________
SIGNATURE NOTARY PUBLIC EMBOSSER SEAL

STATE OF

COUNTY

SUBSCRIBED AND SWORN BEFORE ME, THIS DAY OF
NOTARY PUBLIC SIGNATURE MY COMMISSION EXPIRES

USE RUBBER STAMP IN CLEAR AREA BELOW

NOTARY PUBLIC NAME (TYPE OR PRINTED)

NOTE ^ acknowledgment is cautioned to see that it is properly taken. Do not omit official title of affiants, if corporation.

If the employer is a corporation, signature should be made and seal used according to the laws of Missouri and the official taking this