Free 81A-AI.qxd - Missouri

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS

DIVISION OF WORKERS COMPENSATION
JEFFERSON CITY, MISSOURI

APPLICATION FOR SELF-INSURANCE TRUST
(To be executed and sworn to in triplicate)

ALL INFORMATION CALLED FOR ON APPLICATION MUST BE IN TYPEWRITTEN FORM

The undersigned Trust Fund hereby makes application to carry its own liability without insurance as provided in the Missouri Workers Compensation Law. In connection with such application it makes the following declaration for the purpose of enabling the Division of Workers Compensation to determine whether it possesses sufficient financial ability to render certain the payment of compensation which 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 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.
_________________________________________________________________________________________________ (Effective Date) Official Name of Trust Fund 1. Address of Principal Office ________________________________________________________________________
(Number) (Street) (City) (State) (Zip Code)

2. Trustees

Name

Business Address _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________

____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________

3. Administrator ___________________________________________________________________________________
(Name) (Address) (Telephone Number)

4. Claims Program _________________________________________________________________________________
(Name of Service Company) (Address) (Telephone Number)

5. Safety Program __________________________________________________________________________________
(Name of Person Responsible) (Telephone Number) WC-81A (8-99) AI

6. Total Number of Employer Members ______________ (Attach List of Members) Excess Carrier ________________________________ Policy Number ________________________________ 7. Applicant will Submit: A. Specific Excess Insurance Policy Limit Retention Term B. $____________________ $____________________

Total Estimated Premium ________________________ Trust Experience Mod. __________________________ Standard Premium ______________________________ Estimated Collectible Premium After Discount _________________________

C.

Surety Bond Amount Bond Number $____________________ ____________________

_______________ to _______________ D.

Carrier _________________________________ Fidelity Bond Amount Bond Number $____________________ ____________________

Aggregate Excess Insurance Policy Limit Term $____________________

_______________ to _______________

Loss Fund ______% of collectible premium after any discount Loss Fund Loss Limit $____________________ $____________________

Carrier _________________________________

Est. Min. Loss Fund $____________________ In consideration of the privilege of being a self-insurer, we hereby agree: a. b. c. d. That we will discharge our liability for compensation to injured employees or their dependents in accordance with the requirements of the Workers Compensation Act of the State of Missouri. That we will follow the Administrative Rules of the Division and any additional conditions imposed by the Division as part of our approval. That we will promptly furnish all reports to the Division of Workers Compensation which it may lawfully require under the Workers Compensation Act. That we will notify the Division of Workers Compensation promptly of any unfavorable turn in our financial condition which might reasonably reduce our ability to carry our own risk under the Workers Compensation Act.

We affirm all information submitted as being true.
(Group Fund)

_____________________________________________

by
(Official Title)

_____________________________________________
WC-81A-2 AI

Date ______________________________

_________________________________________________________________________________________________ Name of Trust Fund Effective ____________________ to ____________________ Amount of Payroll by Classification for Current Year of Trust Fund Code ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ Classification __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ TOTALS Payroll _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ Standard Premium Manual Premium _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________

Loss History Experience Date _____________________ year _____________________ year _____________________ year _____________________ year _____________________ year Gross Payroll _____________________ _____________________ _____________________ _____________________ _____________________ Total Losses _________________________ _________________________ _________________________ _________________________ _________________________

Losses over $10,000 past 5 years: Date _____________________ year _____________________ year _____________________ year _____________________ year _____________________ year Total Amount _____________________ _____________________ _____________________ _____________________ _____________________
WC-81A-3 AI