Supplemental Information Addendum To Group Sel-Insurance Fund Annual Report {LIBC-365}

DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION 002 002 002 1. 2. FUND ADMINISTRATOR FISCAL AGENT 002 002 002 Name of fund Insurer code Telephone Email APPLICATION CONTACT Telephone Email Telephone Email 3.Excess InsuranceProvide the following information about the Fund222s excess insurance coverage: (if applicable) Retention amount: $ $ Liability limit: $ Statutory $ Statutory Cash Flow Protection (if applicable) First Year: $ Second Year: $ Third Year: $ Insurer Policy number Effective period: From To -- -- American LegalNet, Inc. www.FormsWorkFlow.com 002 002 002 4.Fidelity CoverageProvide $ $ $ $ $ $ $ $ Insurer Policy number Effective period: From To -- -- 5.Provide the following information about the Board of Trustees (attach additional sheets if necessary).Name of Trustee Title or Position 6.Aggregate Financial InformationIf the members are private employers, provide the following (calculated according to generally acceptedaccounting principles): 002 002 002 American LegalNet, Inc. www.FormsWorkFlow.com 002 002 002 002 ACKNOWLEDGEMENTS AND AGREEMENTS002 compensation liability. determined by the bureau, the bureau may revise the conditions previously set for the issuance of the fund222s permit. The to authorities. By Signature --First name M Last name Title Employer Information Services Claims Information Services Hearing Impaired Email *365*002 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com