STATE OF LOUISIANA Louisana Worforce Commission OFFICE OF WORKERS' COMPENSATION Post Office Box 94040 Baton Rouge, Louisiana 70804-9040 (225) 342-7852 Kathleen Babineaux Blanco GOVERNOR John Warner Smith SECRETARY SERVICE COMPANY APPLICATION CHECKLIST Title 40 Section 1715 requires the following of Service Company Applicants. The application must be accompanied by a $200 application fee made payable to the Office of Workers' Compensation. The application must be fully completed and signed by an official of the company authorized to do so. The application must also be properly notarized as indicated. All applicants must be accompanied by resumes' of applicant's personnel qualified in the areas of claims adjusting, safety engineering\loss control, and underwriting. Please note that each applicant must have at least one person, employed on a full-time basis, with two or more years of experience processing Louisiana Workers' Compensation Claims. Please also note that the detailed resumes' of the employees must actually list past employers along with experience in past positions. Each resume' should indicate the length of time the employee has been with the service company applicant. The service company applicant is required to submit detailed background information on its' company. (Brochures, Pamphlets, etc.) A sample contract which details the full spectrum of services that will be provided by the applicant to qualified self-insurers is also required. NOTE: Once your application is reviewed, if approval of your service company program is granted by our office, you will be required to promptly inform our office of any significant changes in ownership, company structure or personnel. Service companies are also required to remit a $200.00 re-application fee annually without prompting from our office. If you require assistance, please contact the Audit & Security Division at either (225) 342-5658 or 1-800201-3448. AN EQUAL OPPORTUNITY EMPLOYER American LegalNet, Inc. www.FormsWorkflow.com