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Application To Create Self-Insurance Fund Form. This is a South Carolina form and can be use in Workers Comp.
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Tags: Application To Create Self-Insurance Fund, 6, South Carolina Workers Comp,
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
7. Where to Direct Self-Insurance Tax and Financial Information
Address
Contact Person
Telephone Number
(
)
-
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
By:
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Applicant’s Name
Signature
Sworn and subscribed before me this
day of
,
.
Notary Public for:
My commission expires:
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
