Self-Insured Employers Application To Add A Subsidiary {A-05S}

STATE OF MARYLAND WORKERS' COMPENSATION COMMISSION 10 East Baltimore Street · Baltimore · Maryland · 21202 (410) 864-5100 · (800) 492- 0479 web - http://www.wcc.state.md.us SELF-INSURED EMPLOYER'S APPLICATION TO ADD a SUBSIDIARY Part I - General a. Approved Self-insured Employer: Name: Address: Street City Telephone: Contact Person: Email address: Federal ID Number: State FAX: ZIP Code b. Maryland Claims Administrator (Not the Attorney of Record): Company name: Address: Street City Telephone: Representative Name: Email address: State FAX: ZIP Code c. Applicant Subsidiary Subsidiary Name: Home Office Address: Street City Telephone: Date Acquired: Contact Person: Email address: Maryland Address: Street City Telephone No: Division Affiliate Other (explain) Federal ID Numbe r: State FAX: Date of Incorporation: Requested Effective Date: ZIP Code State FAX: ZIP Code Form A-05S (rev 12/2006) Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com STATE OF MARYLAND WORKERS' COMPENSATION COMMISSION 10 East Baltimore Street · Baltimore · Maryland · 21202 (410) 864-5100 · (800) 492- 0479 web - http://www.wcc.state.md.us Part II - Employment and Related Data Principal workers compensation classification of employees : Please provide the following information for the subsidiary for each year of the last three years prior to filing this application: Dates From To No. of Employees Annual Maryland Payroll Experience Modifier Workers' Compensation Premiums For the last 12 months prior to filing this application, please provide the following for the subsidiary: Classes of Employees (NCCI Codes) No. of Employees (in each class) Annual Payroll (for each class) (If additional space is required, please attach a separate sheet clearly marking the name of the self-insured employer and the name of the subsidiary, affiliate or division.) No. of Accidents (SF-1issued): during the last 12-month period ending: Form A-05S (rev 12/2006) Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com STATE OF MARYLAND WORKERS' COMPENSATION COMMISSION 10 East Baltimore Street · Baltimore · Maryland · 21202 (410) 864-5100 · (800) 492- 0479 web - http://www.wcc.state.md.us Total claims incurred, including medical and indemnity, both paid and additions to reserve, for the following: Period Covered The last 12 month period Prior 12 months Second Prior 12 months TO FROM AMOUNT Part III - Certification I certify that to the best of my knowledge and belief, the information contained in this application is true and correct. Name of Approved Self-Insurer: By: _______________________________________ (Signature) Title: (Printed Name) Date: NOTE: A. If the unit being added to your self-insurance program is a subsidiary or an affiliate you must complete a Parental Guarantee & Board Resolution (MD WCC form A-04, 9/2006) [see our web FORMS page at http://www.wcc.state.md.us for forms and additional information]. This is not required for a division. County and municipal governments adding units are assumed to guarantee all entities included in their self-insurance programs. B. Provide the three most current years of audited financial statements for the subsidiary. C. A $250.00 non-refundable fee, check made payable to MD Workers' Compensation Commission., must accompany this application. Form A-05S (rev 12/2006) Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com