Free Form SI-12 Rev. 8/01/2006 Ark. Code Ann. §11-9-404 & AWC C Rule 099.05 ARKANSA... - Arkansas

Form SI-12
Rev. 8/01/2006 Ark. Code Ann. §11-9-404 & AWC C Rule 099.05

ARKANSAS WORKERS' COMPENSATION COMMISSION

SELF-INSURANCE DIVISION
324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-2783 / 1-800-622-4472

SI-12

APPLICATION FOR MEMBERSHIP IN A GROUP
Name o f Group Self-Insurer:

Name o f App licant:

Telephone N umber (

)

Facsimile Number ( Mailing Address:

)

City, State, and Zip Code:

Years in Business:

Application is for:

Federal Employer Identification Number

G Individual G Partnership
Nature o f Business:

G Corporation G Other (please specify)

(FEIN):

PH YS ICA L LO CATION S: List physical address, city, state, and zip code - (If more locations, please list on a separate page and attach.) 1. 2. 3. 4. 5. 6. Name of officers, owners or partners, and addresses (First name) 1. 2. 3. 4. 5. (MI) (Last name ) (Title) (Address) Include for Coverage

G Yes G Yes G Yes G Yes G Yes

G No G No G No G No G No

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Form SI-12 (Rev. 8/01/2006)

NOTICE: THE INFORMATION IN ITEMS 1 - 5 BELOW IS CONFIDENTIAL
1. 2. Number of employees working for applicant in Arkansas at this time____________________________________________________ Arkansas workers' compensation and employer's liability insurance coverage prior to effective date carried by:__________________ ___________________________________________________________________________________________________________ 3. 4. What is the expiration date of applicant's current workers' compensation coverage? _________________________________________ List the class cod es and descriptions used on the applicant's existing o r previous wo rkers' compe nsation policy. If the applicant is a new entity, skip this step and proceed with number 5. (Attach an additional sheet if more space is needed) MANUAL CODE DESCRIPTION

5.

Please complete the following, based on the preparation of the proposed group policy NO. OF MANUAL CODE CLASSIFICATION PAYROLL RATE PER $100 ANNUAL PREMIUM

EMPLOYEES

To tals Experience Modifier ________________

$ Experience M odifier Discount Premium Size D iscount Front-End Discount Total projected premium to be paid for the policy period

$ $ $ $

Premium Size Discount ________________% Front-End Discount ________________%

$

6.

W e hereby formally apply for continuing membership in the above named group, to be effe ctive at 12:01 A.M. __________________________, 2____ _____ _, and if accepted by the group's duly authorized repre sentative, do hereby designate and appoint the named manager of the Group as our agent-in-fact in all matters relating to the workers' compensation laws and/or emp loyer's liab ility.

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Form SI-12 (Rev. 8/01/2006)

W e further agree as follows: A. B. To accept and be bo und by the p rovisions of the Arkansas workers' comp ensation laws. That, by application and reference, the terms and provisio ns of the Gro up Indem nity Agre ement and/or Amendme nt thereto filed, or any renewal Indemnity Agreement which may hereafter be filed with the Arkansas Workers' Compensation Commission are hereby adop ted, ap proved, ratified and confirmed by us: and, further, we agree to assume all of the obligations set forth therein, including, but not limited to, our joint and several liabilities for payment of any lawful awards against any member of the Group. C. To abide by the rules and regulations of the Trustees of the Group and to conform to the terms of the agreements they may enter into with any authorized third party administrator as long as we remain a member of the group. D. W e agree to give at least thirty (30) days written notice to the Group prior to our withdrawal as a member. In the event, of any changes in ownership, corporate structure, legal entity, nature of business or if any locations are to be added or deleted, we agree to so notify the Group immediately. The Group will give written notice thirty (30) days prior to cancellation or expulsion of any member.

_________________________________________________
(Na me o f applicant)

________________________________________________
(Printed N ame of autho rized officer o f App licant)

________________________________________________
(Signa ture of authorized o fficer of Applicant)

________________________________________________
(Title of officer) State of Arkansas County of ___________________________A Subscribed and sworn to me by ____________________________________________________________ on this _______________ day of _______________________________, 2__________. ___________________________________________________ No tary Public My Commission Expires: _____________________________

The application and supporting documents of _________ _________ _________ _________ _________ have been properly received and noted . Said applicant is here by approved and accep ted for membership in the Group effective the __________ day of ________________________, 2 ______. ____________________________________________________________________ (Name of Group)

By:

____________________________________________________________________ Chairman, Board of Trustees

____________________________________________________________________ Date of Signing

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Form SI-12 (Rev. 8/01/2006)