Group Application Checklist {WC-239}

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058 GROUP APPLICATION CHECKLIST Group application Individual member applications (At least 10 members with separate ownership. Net worth of all members combined, not less than $5,000,000.) financial experience modification rate sheet loss runs (three-year minimum) proof of deposit (25% or more) By-laws of trust By-laws of association Trust/indemnity agreement Combined EAP for group (at least $1,000,000) Combined loss history Excess Binder/COI (AM best rated, A- or better) (specific & aggregate) Escrow agreement/surety bond (not less than $500,000) Executed service agreement copy of TPA license List of board members and their titles ­ include address and phone number List of administrators and marketers ­ include address and phone number Projected expenses (not to exceed 30% of actual premiums collected) Check for $500.00 ­ nonrefundable filing fee Underwriting guideline Safety program ­ visit by safety Fiscal year Combined financial statements Rates by classification codes Fidelity bond/employee dishonesty ­ not less than $1,000,000 trustees plan administrator claims administrator marketers Director's and officer's/errors and omission/professional liability trustees plan administrator claims administrator marketers Security to be determined by the Division but not less than $500,000. Escrow: US Government obligations only. T-bills, notes or bonds deposited in Missouri bank only. Surety Bond: issued by a company AM best rated, A- or better and admitted by the Missouri Department of Insurance to transact such business in the state of Missouri. WC-239 (09-11) AI American LegalNet, Inc. www.FormsWorkFlow.com