Request For Information (To Accompany Form SI-02)

KENTUCKY DEPARTMENT OF WORKERS' CLAIMS Frankfort, Kentucky 40601 REQUEST FOR INFORMATION It is the responsibility of each self-insured employer to provide the Department of Workers' Claims with accurate, up-to-date information for our records. The Self Insurance Branch is to be informed of any change in the administration of the self-insured employer's Workers' compensation program, including contact names, telephone numbers, third party administrators, and self-administered policies. To the Department of Workers' Claims: , 20 Applicant: Company Name: Self-Insurance Inception Date: Federal Employer ID Number: Address: City: County: Contact Name: Phone: Email: Fax: State: Zip: Administration of Self-Insurance Program: Is the administration of the self-insurance program handled in-house? Yes No If the administration of the self-insurance program is handled by a Third Party Administrator, please provide the following information: Company Name: Address: Contact Name: Phone: Email: Fax: Attachment 1 American LegalNet, Inc. www.FormsWorkFlow.com KENTUCKY DEPARTMENT OF WORKERS' CLAIMS Frankfort, Kentucky 40601 REQUEST FOR INFORMATION Claims Administration: Is the administration of claims handled in-house? Yes No If No, you must list the current and all previous Third Party Administrators in chronological order for the entire selfinsurance period. Current Company Inception Date: Company Name: Address: Contact Name: Phone: Email: Fax: Former Company Inception Date: Company Name: Address: Contact Name: Phone: Email: Fax: End Date: If additional pages are needed in order to list all former TPA's, please utilize the format above. Attachment 2 American LegalNet, Inc. www.FormsWorkFlow.com KENTUCKY DEPARTMENT OF WORKERS' CLAIMS Frankfort, Kentucky 40601 REQUEST FOR INFORMATION Subsidiary/Division/Location Information: Please list all entities (including all subsidiaries and divisions) doing business within the Commonwealth of Kentucky that are to be included under the self-insurance program. Divisions should be listed under the appropriate corporate name. The corresponding address of each work location is to be included. Please Note: Self-Insurers Guarantee Agreement (Form SI-01) must be on file for each subsidiary listed. If there is no Guarantee Agreement on file, the subsidiary will not be listed as being covered under the self-insurance program. It is the responsibility of the self-insured employer to notify the Self-Insurance Branch of any and all changes involving the subsidiaries, divisions, and work locations located within the Commonwealth of Kentucky. Written notification should be forwarded to The Department of Workers' Claims Self-Insurance Branch at the earliest opportunity indicating any locations to be added to or deleted from the self-insurance program as well as any changes in name or address of work locations. Subsidiary: Name: Address: FEIN: Division: Locations: 1. (Name and Address) A. (Name and Address) Division: Location: 2. (Name and Address) A. (Name and Address) If additional pages are needed in order to list all entities to be included, please utilize the format above. Please ensure that this `Request for Information' page is completed in its entirety in order for the Self-Insurance Certification process to be completed. It is the policy of the Department of Workers' Claims Self-Insurance Branch for this information to be provided each year as part of the recertification process. This information is essential in maintaining complete and accurate records on all Self-Insured employers. Please Note: The self-insured employer is responsible for notifying the Department of Workers' Claims Self-Insurance Branch, in writing, of any changes to this information which occur at any time during the approved period of self- insurance. Attachment 3 American LegalNet, Inc. www.FormsWorkFlow.com