BI-BL1 01/06 Application for Coverage under Coal-Workers’ Pneumoconiosis Fund BrickStreet use only C.W.# Status Class Return complete form to: BrickStreet Mutual Insurance P.O. Box 3064 Charleston, WV 25332-3064 Telephone: (304) 926-3400 Fax: (304) 926-1996 County Effective Date Wages Rate Remitted The undersigned hereby applies for coverage by the Coal-Workers’ Pneumoconiosis Fund of the State of West Virginia of liability created by Title IV of the Federal Coal Mine Health and Safety Act of 1969, as amended, and as provided in Article 4B, Chapter 23 of the West Virginia Code, as amended, and further agrees by making this application to be bound by the rules and regulations of the Coal-Workers’ Pneumoconiosis Fund. Failure of the subscriber to timely file quarterly payroll and premium reports and to pay any premium due shall result in action taken by the Fund to cancel the subscriber’s insurance coverage. A . I DE N T I F I C A T I O N O F A P P L I C A N T . 2. Telephone number (include area code) 1. Name 3. Address Street or P.O. Box City 4. Type of Business entity: (check one) Sole proprietorship 5. Date licensed to do business in WV (attach verification) / County Corporation State Partnership Other: 6. If a corporation: (attach verification) Date of incorporation / State of incorporation: Zip Code / 7. BrickStreet Policy Number / 8. If a corporation, partnership, or sole proprietor, list names and social security numbers of officers or owners US E B L A CK IN K. 9. Is the applicant a lessee? Yes No If yes, provide the name and address of the lessor and attach copies of the lease agreements. 10. Is the applicant a subsidiary of any other business entity? Yes If yes, provide the name and address of the parent organization. 11A. Is the applicant a transferee or successor of another business entity? Yes No If yes, provide the name and address of the transferor or predecessor entity (attach copies of all documents and agreements of transfer or succession.) 12. Address at which a field auditor may conduct an audit of your payroll 11B. Has the applicant ever had coverage before? If yes, what was the policy number? Yes No No Contact person: Telephone number: B . E MP L O Y E E & P A Y R OL L I N F O R MA T I O N P R E V I O U S T O A P P L I C A T I O N . 1. Date you began coal mine operations 2. Estimated average number of employees: 3. Estimated gross payroll: / For the next three months: $ For the next year: / For the next three months: For the next year: $ 4. Total estimated gross payroll for all operations for the next three months: Underground $ Surface $ C . O PERATIONS INFORMATION MUST BE GIVEN FOR ALL W EST VIRGINIA OPERATIONS . ATTACH ADDITIONAL SHEETS IF MORE SPACE IS NEEDED . 1. Name of operation 2. Location (include county) 3. Federal Mine Identification Number 4. Type of operation 5. Federal Employer’s Identification Number (FEIN) 6. Date operation began or will begin Underground Surface Trucking / / Other (explain) CERTIFICATION I certify, swear, or affirm that all of the statements made and information provided within or accompanying this application are true, complete, and correct to the best of my knowledge and belief and are made in good faith. Signature of owner or principal officer (sign in ink) Title Date BrickStreet Mutual Insurance  P.O. Box 3064  Charleston, WV  25332-3064 American LegalNet, Inc. www.USCourtForms.com