Employers Application For Individual Self Insurance {S120}

COMMONWEALTH OF VIRGINIA VIRGINIA WORKERS' COMPENSATION COMMISSION 333 E. FRANKLIN STREET , RICHMOND VA 232 19 Employer's Application for Individual Self - Insurance Under the Virginia Workers' Compensation Act Note - Under rule, adopted by the Commission, November 20, 1918, all information given in this application is strictly confidential. To the Virginia Workers' Compensation Commission: The undersigned, an employer subject to the provisions of the Virginia Workers' Compensation Act, hereby applies for the privilege of being exempt from the necessity of insuring the payment of compensation provided in that act, and submits th e following facts under oath to the Virginia Workers' Compensation Commission to enable it to determine if sufficient financial ab ility exists to render certain the payment of such compensation: 1. Applicant: Name: Address: City, St ate, Zip: 2. Corporate information: 2a. The applicant is a: (Sole proprietorship, partnership, limited partner ship, corporation, trustee.) Federal tax identification number (FEIN): - 2b. If a corporation, indicate the State and date of the charter: State: Date: 2c. If a subsidiary, indicate the name and address of the parent company: Name: Address: City, State, Zip: 2d. If a limited partnership, give date of formation and duration: Date: Duration: 2e. List the names of all subsidiaries and/or operating entities doing business in Virginia: 2f. List below the names and residences of officers, directors, partners, or the sole proprietor: Name Address THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE VIRGINIA WORKERS' COMPENSATION ACT. VWC Form No. SI 20 (rev. 11/ 6/17 ) American LegalNet, Inc. www.FormsWorkFlow.com 3. Descripti on of operations: 3a. Describe briefly the general character of the operations performed and the articles manufactured or compounded at or away from the plant or premises of the applicant: 3b. Indicate the Standard Industrial Code Number for t his business: 3c. List below the Virginia locations, including a brief description of the nature of operations, and the number of employees: Location Type of operations Number of employees 3d. List below the Virg inia payroll, broken down by NCCI payroll classification codes: NCCI code Estimated annual payroll 4. Summary of financial situation for the past three years: 20 20 20 Total assets Total liabilities Net wor th A complete set of audited financial statements for the last three years must accompany this application. American LegalNet, Inc. www.FormsWorkFlow.com 5. Safety conditions: 5a. Is your plant inspected otherwise than by State authority? Yes No If so, by whom? 5b. Have you fulfilled all safety requirements of the State Department of Labor and Industry? Yes No 5c. Do you have a safety committee whose duty it is to recommend safety devices and to secure compliance with statutes or general orders of the Department of Labor and Industry as to safety and sanitation? Yes No 6. Summary of claims experience for the last three years: 20 20 20 Total number of injuries Number of injuries with 7 or more days lost time Number of dismemberments Number of fatal cases Total compensation paid Total medical paid Total compensation incurred Total medical incurred A detailed report reflecting your claims history for the last three years must accompany this application. 7. Insurance information: 7a. Date self - insurance is to become effective (must be at least 90 days after application is filed): 7b. Indicate the limits of planned excess insurance coverage: Specific retention Aggregate retention Specific limit Aggregate limit 7c. Indicate below any other states in which you are operatin g as a self - insurer for workers' compensation: 7d. Provide the following information regarding your current workers' compensation insurance coverage: Insurance carrier: Policy number: Policy period: 7e. List below other insurance that you carry (type and amount): American LegalNet, Inc. www.FormsWorkFlow.com 8. Cla ims administration: 8a. Proposed claims administrator (use additional sheets if there are multiple locations): (Individual) (Name of Company) (Mailing Address) (City, State, Zip) (Telephone Number) 8b. In - state designated representative: (Individual) (Name of Company) (Mailing Address) (City, State, Zip) (Telephone Number) 9. In consideration of the approval of this application, the applicant hereby expressly agrees to the following: 9a. The applican t will pay all benefits required by the Virginia Workers' Compensation Act. 9b. If the Virginia Workers' Compensation Commission so requires, the applicant will deposit with the said Commission acceptable security, indemnity or bond to secure payment of compensation liabilities as they are incurred. Additional security, indemnity or bond may be required in the future. 9c. If the applicant is a subsidiary company or a partnership, the applicant will, if required by the Commission, provide certificati on that the parent company (or a partner or partners) guarantees that the applicant will fully and promptly pay all sums which are or may become payable under the provisions of the Virginia Workers' Compensation Act and under the terms of the agreement con tained in this application. 9d. This privilege may be revoked at any time in the discretion of the Virginia Workers' Compensation Commission, as provided in Section 65.2 - 808 of the Act. 9e. The applicant will comply with the Regulations Governing Individual Self - Insurance, as provided in 16 VAC 30 - 80 - 10 of the Act. Signature of Applicant Official Title City/County of : , being first duly sworn, appeared personally and declared that the facts set forth in the foregoing application are true to the best of his or her knowledge, information and belief. Subscribed and sworn to before me, this day of , . (Seal) (Seal) Notary Public My commission expires on the day of , . American LegalNet, Inc. www.FormsWorkFlow.com