Application For Membership In Self-Insured Fund {6A}

South Carolina Workers' Compensation Commission SELF-INSURANCE DIVISION 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5706 Page 1 of 2 APPLICATION FOR MEMBERSHIP IN A SELF-INSURED FUND 1. 2. 3. 4. 5. 6. Fund Name: Applicant's Name: Applicant's Address: Applicant's Telephone Number: Employer's Federal Identification Number: The Employer is a (check one): (A) Corporation: Attach a list of officers and their residential addresses. (B) Partnership: Attach a list of officers and their residential addresses. (C) Sole Proprietorship: Name and Residence: ( ) - (D) Other: Explain 7. Who is your present workers' compensation insurance carrier: 8. In the most recent fiscal year what was your workers' compensation premium and experience modification for South Carolina? Premium Amount: Experience Modification: 9. List all employment locations in South Carolina (provide an attachment if necessary). Locations Number of Employees 10. Provide the following information for workers' compensation claims information for South Carolina for the past three years. Year Number of Claims Amount Paid Amount Incurred For further information, refer to Article 15 of the South Carolina Workers' Compensation Commission's Regulations. WCC Form # 6A Created 3/96 6A APPLICATION FOR MEMBERSHIP IN A SELF-INSURED FUND American LegalNet, Inc. www.FormsWorkFlow.com South Carolina Workers' Compensation Commission SELF-INSURANCE DIVISION 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-5706 Page 2 of 2 11. Describe the nature of your business, including products manufactured, sold or services provided. 12. Provide the following employment information for the current year. Year Employee Class Codes Number of Employees Estimated Payroll 13. Attach a current financial statement. 14. Attach a $25.00 application fee. Make the check payable to the South Carolina Workers' Compensation Commission. In consideration of the approval of this application, the applicant agrees to fully comply with the terms of the South Carolina Workers' Compensation Commission Act and Regulations. If the applicant is approved, it is agreed and acknowledged that the applicant, along with the other members of the Fund, will be jointly and severally liable for any liability of the Fund which is incurred during the applicant's membership in the Fund. By: Applicant's Name: _______________________________________________________________________________ Signature: _____________________________________________________________________________________ Sworn and subscribed before me this ______ day of _____________ year _____________ Notary Public for: _______________________________________________________________________________ My commission expires: __________________________________________________________________________ Reserved for Commission Use Only Fund Number : _________________ Effective Date: ________________ For further information, refer to Article 15 of the South Carolina Workers' Compensation Commission's Regulations. WCC Form # 6A Created 3/96 6A APPLICATION FOR MEMBERSHIP IN A SELF-INSURED FUND American LegalNet, Inc. www.FormsWorkFlow.com