SUPPLEMENTAL APPLICATION SUBSIDIARY COVERAGE FOR WORKERS' COMPENSATION SELF-INSURERS ______________________________________________________________, a corporation duly organized under the laws of the State of ____________________________________________, which has previously been approved by the Industrial Commission of the State of Idaho to act as a workers' compensation self-insured employer, hereby applies for extension of such authority to self-insure to the following wholly-owned subsidiary corporation(s) of such parent corporation: NAME FEIN ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ _____________________ _____________________ _____________________ _____________________ In support of such application, the applicant hereby certifies as follows: 1. is as follows: That the three-year average payroll of its wholly-owned subsidiary corporation(s) 20__: 20__: 20__: $_______________ $_______________ $_______________ Average: $_______________ 2. That it has made an additional deposit with the Idaho State Treasurer in the amount of $_______________, in the form of _______________________________________ equaling 5% of the average annual payroll for the wholly-owned subsidiary corporation(s) (subject to the maximum limitations set out in the regulations relating to self-insured employers), together with all outstanding and unpaid awards of compensation against such wholly-owned subsidiary corporation(s) under the Idaho Workers' Compensation Law. 3. That its resident claims adjuster previously designated shall have full authority to handle all workers' compensation claims against the wholly-owned subsidiary corporations(s) of the undersigned to the same extent as if they were against the undersigned. Supplemental Application - Subsidiary Coverage Self-Insured Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 4. That it agrees to assume and guarantees to pay all of the liabilities and obligations which the wholly-owned subsidiary corporation(s) may incur under the workers' compensation laws of the State of Idaho, including past, existing, future or potential claims for workers' compensation benefits, court costs, attorney fees, or other assessments against such whollyowned subsidiary corporation(s). 5. In the event that an application for hearing is filed with the Industrial Commission naming such subsidiary as the employer, the undersigned does hereby agree that it can be named as a party to or in lieu of such subsidiary and agrees to submit to the jurisdiction of the Idaho Industrial Commission and to pay all compensation awarded in the same manner that the subsidiary would have been required to pay. 6. This agreement shall not cover or extend to any workers' compensation liabilities of such subsidiaries which are expressly insured by a carrier duly authorized to write Idaho workers' compensation insurance. 7. That the last annual statement of the assets and liabilities of each subsidiary for which application is made, is attached hereto. 8. The wholly-owned subsidiary corporation(s) shall comply with the reporting, claims handling, premium tax payment, and other requirements of the Idaho Workers' Compensation Law, and the parent corporation understands and agrees that the failure of such subsidiary corporation(s) to comply with those requirements may be grounds for revocation of the authority to extend self-insured coverage to such wholly-owned subsidiaries, as well as the self-insured status of the parent corporation. 9. That it agrees as a condition to the granting of the authority requested to execute such amendments to its self-insurer's compensation bond, and/or the power of attorney on file with the State Treasurer's office, as are necessary to make those documents applicable to workers' compensation claims against such wholly-owned subsidiary corporation(s). 10. In the event that such subsidiary corporation(s) shall fail to pay compensation as compensation is defined in the Idaho Workers' Compensation Law, when due, or the premium tax payment required by law, the undersigned shall pay the same, and payment may be enforced against the undersigned to the same extent as if said payment was the direct liability of the undersigned. 11. As provided in Idaho Code, §72-301(2), the approval by the Commission of any Supplemental Application - Subsidiary Coverage Self-Insured Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com self-insured employer may be withdrawn if it shall appear to the Commission that workers secured thereby under the law are not fully protected. DATED this ____________ day of _______________________________, 20_____. X______________________________________________ (Signature) By_____________________________________________ (Print Name) ________________________________________________ Title STATE OF ____________________) COUNTY OF __________________) On this __________ day of ____________________, in the year 20_____, before me personally appeared ________________________________________________________, known to me to be the person whose name is subscribed to the within instrument, and acknowledged to me that he executed the same. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal, the day and year in this certificate first above written. __________________________________________ Notary Public for ___________________________ Residing at ________________________________ My commission expires on ___________________ Supplemental Application - Subsidiary Coverage Self-Insured Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com