Form SI-1 ARKANSAS WORKERS’ COMPENSATION COMMISSION Rev. 8/01/2006 Ark. Code Ann. §11-9-404 & AWC C Rule 099.05 SELF-INSURANCE DIVISION SI-1 324 Spring Street, Little Rock, AR 72201 Mail: P. O. Box 950, Little Rock, AR 72203-0950 501-682-2783 / 1-800-622-4472 INDIVIDUAL SELF-INSURER APPLICATION To the Arkansas Workers' Compensation Commission: The undersigned, an employer subject to the provisions of the Arkansas workers' compensation laws, hereby applies for the privilege of becoming a self-insurer for the payment of compensation and submits the following facts, under oath, to the Arkansas Workers' Compensation Commission for determination if sufficient financial ability exists to render certain the payment of such compensation: (Where space is insufficient to answer any question, extend answer on an attached page or pages.) 1. Name of applicant ________________________________________________________________________ 2. Federal Employer Identification Number _________________________________________________________ 3. Address - principal office ____________________________________________________________________ (Number) (Street) (City or Town) (County) (State) (Zip) Telephone No. ________________ Fax No._____________________ Toll-free No. ___________________ List the location and address of each facility in Arkansas_____________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________________________________________________________________________ 4. The applicant is ___________________________________________________________________________ (State specific type of business, such as corporation, partnership, limited partnership, limited liability corporation etc.) 5. Is the applicant a subsidiary? G Yes G No. If yes, give name, FEIN, and address of parent company_________ _________________________________________________________________________________________ 6. Describe briefly the general character of the operations performed and the articles manufactured or compounded at or away from the plant or premises of the applicant._____________________________________________ __________________________________________________________________________________________ _______________________________________________________________________________________ __________________________________________________________________________________________ 7. Date when self-insurer status is desired _______________________________________________at 12:01 A.M. 8. Date business established _____________________________________________________________________ If corporation, under laws of what state?________________________________________________________ 9. Did you succeed anyone? G Yes G No If yes, whom? ____________________________________________ Page 1 of 4 Form SI-1 (Rev. 8/01/06) American LegalNet, Inc. www.FormsWorkflow.com NOTE: ALL INFORMATION ON THIS PAGE IS CONFIDENTIAL 10. The following payroll facts are for the twelve- month period ended (date) _____________________________ AMOUNT OF ARKANSAS PAYROLL BY OCCUPATIONAL CLASSIFICATION* No. of Manual Employees Classification Payroll Rate Per Code $100 Total premiums paid for the above period * Annual Premium $ As furnished by your insurance carrier, if insured. If a new company, provide projected payroll for a one-year period. 11. If the financial statement provided for evaluation is not in the name of the applicant, please indicate the name of the company and FEIN (Federal Employer Identification Number) whose financial statement is being provided. This financial statement is to be a certified, audited, bound statement. Date of Statement: ___________________ Name: _____________________________________________________ FEIN:______________________ 12. If a corporation, list below the names of officers, directors, and addresses of each: _______________________________________________________________________________________ __________________________________________________________________________________________ If a partnership, list the names of general or limited partners and addresses of each: _____________________ _______________________________________________________________________________________ __________________________________________________________________________________________ Sole owner: ___________________________ Address: _________________________________________ 13. What company now is carrying your compensation insurance? _____________________________________ Were you assigned to this carrier? G Yes G No Current Expiration Date: __________________________ 14. Who will serve as applicant's in-house staff administrator? __________________________________________ E-Mail Address: ______________________________________ Toll-Free: ___________________________ Address: ________________________________________________________________________________ Direct Telephone No.: _________________________________ Fax No.: ____________________________ 15. Workers’ Compensation claims will be handled by G Self-Administer G Third Party Administrator Name: _________________________________________________________________________________ E-mail Address (if self-administering) _________________________________________________________ Address: ________________________________________________________________________________ Telephone No.: ___________________ Fax No.: ___________________ Toll-Free: ____________________ Page 2 of 4 Form SI-1 (Rev. 8/01/06) American LegalNet, Inc. www.FormsWorkflow.com 16. Do you plan to reinsure any part of the compensation risk? G Yes G No If yes, between what limits? Specific retention $______________________to $ ______________________ Aggregate? G Yes G No 17. Safety, sanitation and welfare conditions: Is your plant inspected by anyone other than a state authority? G Yes G No If yes, by whom?______________ __________________________________________________________________________________________ 18. Is your company self-insured in any other state? G Yes G No If yes, where? __________________________ ______________________________________________________________________________________ ________________________________________________________________________________________ __________________________________________________________________________________________ 19. Past accident experience: (workers' compensation only) NOTE: INFORMATION IN ITEMS 20 C, D, E, F, & G IS CONFIDENTIAL A. B. C. D. E. F. G. Fiscal Current Number of Deaths Number of Injuries No. of Accidents of all Total Compensation Estimated Amount Year Experience Causing Disability of Kinds including those & Medical Paid Payable on Modifier 8 days or longer not compensable) Outstanding Cases 20. In consideration of the approval of this application, the applicant hereby expressly agrees as follows: (a) That this privilege may be revoked at any time in the discretion of the Arkansas Workers' Compensation Commission, as provided in Commission Rule 099.05. (b) That the applicant will fully discharge by cash payments all liabilities that may arise under the Arkansas workers' compensation laws. (c) The applicant agrees to deposit, as directed by the Commission, acceptable form of security to secure payment of compensation liabilities in the amount and manner as directed by the Commission. (d) This applicant agrees to pay to the Arkansas Workers' Compensation Commission the premium tax and initial fee of $100.00 as required by law. Page 3 of 4 Form SI-1 (Rev. 8/01/06) American LegalNet, Inc. www.FormsWorkflow.com Impress Corporate Seal Here ______________________________________________________ (Applicant) By ______________________________________________________ (Official and Title) State of ______________________________) ) County of ____________________________) _______________________________________________________, being first duly sworn, appeared personally and declared that the facts set forth in the foregoing application are true to the best of his/her knowledge, information and belief. Subscribed and sworn to before me this ____________ day of ______________________________, 2 ______. (Seal) ______________________________________________ (Notary) My commission expires on the _____________ day of ___________________________, 2 ____________. (This affidavit may be sworn to before any person authorized to administer an oath.) ---------------0--------------IMPORTANT When the applicant is a subsidiary company, the Commission requires that the parent company shall give a satisfactory guarantee that the applicant will fully and promptly pay all sums which are or may become payable under the provisions of the Arkansas workers' compensation laws and under the terms of the agreement contained in this application. Page 4 of 4 Form SI-1 (Rev. 8/01/06) American LegalNet, Inc. www.FormsWorkflow.com