ARKANSAS WORKERS’ COMPENSATION COMMISSION Form O O Eff 1/01/2008 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-2783 / 1-800-622-4472 Rule 099.29 CLAIM OFFICE / ADMINISTRATOR / UNDERWRITER Designation Form Commission Rule 0 99.2 9 req uires the designation o f certain contac ts to facilitate compliance with Arkansas law, Comm ission Rules and the proce ssing of claims. The designations below are to be made only by insurance carriers or self-insured employers. This form is not to be co mpleted by third party adm inistrators, insurance agents or brokers. Insurance Carriers - Please complete the following This form is being filed for: NAIC Com pany Number NAIC G roup Number An Insurance Carrier A Self-Insured Employer or Group Company Name (full legal) FEIN Claim Office: This is to be the o ffice responsible for all Arka nsas workers' compensation claims. Claims are: 9 Self-Ad ministere d (i.e. handled in-house or b y a com pany within the above com pany's corpo rate fam ily) 9 Handled by a T hird Party Administrator (TP A). The T PA must be app roved and authorized by the Comm ission. Claim Office Company Name Mailing Address Complete the remainder of this section only if claims are self-administered. Claims/Office Manager Name Direct Phone E-M ail Fax Toll Free Administrator: This person is to be an employee of the carrier or self-insured employer who is responsible for all Arkansas workers' compensation issues. This person may be an employee of the carrier/self-insured company's parent company if desired. Admin. Company Name Mailing Address Admin. Name Direct Phone Underwriting: (carriers only) E-M ail Fax Toll Free Th is is the carrier contact person for employer covera ge or questions. Underwriter's Company Name Mailing Address Underwriter Name Direct Phone E-M ail Fax Toll Free I, ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ __(printed name ), as an employee of the above carrier/self-insured employer (or it's parent company) make the above designations in compliance with Commission Rule 099.29. Further, we agree to promptly notify the Commission of any changes to the above designations by re-completing and submitting this form. Phone Signature Title Date Form O (Eff 1/1/08) American LegalNet, Inc. www.FormsWorkflow.com