Application To Create Self-Insurance Fund {6}

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 TO CREATE A SELF-INSURANCE FUND 1. Association Name 2. Address 3. Telephone Number 4. Fund Name 5. Address of Fund (if different) 6. Claims Administration Address Contact Person Telephone Number Address Contact Person Telephone Number ( ) ( ) ( ) - 7. Where to Direct Self-Insurance Tax and Financial Information The Employer and the Fund are subject to and shall abide by all requirements of the Workers' Compensation Commission Act, amendments thereto, and regulations that now are or hereafter adopted by the South Carolina Workers' Compensation Commission. Reserved for Commission Use Only Approved:_______________ Effective Date:________________ SI No.________________________ For further information, refer to Article 15 of the South Carolina Workers' Compensation Commission's Regulations. WCC Form # 6 Rev. 04/00 6 Application to Create a Self-Insurance 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 By: Applicant's Name Signature Sworn and subscribed before me this Notary Public for: My commission expires: day of , . Attach the following information: 1. $250.00 application fee. 2. Proposed fund bylaws and/or trust agreement. 3. Completed form 6A for each proposed member and $25.00 application fee for each. 4. List of proposed members giving experience modifications, annual workers' compensation premium amount for South Carolina, number of employees in South Carolina and type of business for each. 5. A list of estimated standard premium to be collected by the Fund each month for the first fiscal year. 6. Three years loss history for each proposed member. Give the number of claims, compensation paid and incurred, medical paid and incurred for each year. 7. Signed indemnity agreement jointly and severally binding each potential member. 8. Statement describing in detail proposed claims administration and loss control. 9. Excess insurance quotes for specific and aggregate coverage. 10. Independent actuary study. For further information, refer to Article 15 of the South Carolina Workers' Compensation Commission's Regulations. WCC Form # 6 Rev. 04/00 6 Application to Create a Self-Insurance Fund American LegalNet, Inc. www.FormsWorkFlow.com