COURT OF COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . DIVISION . . . WORKERS' COMPENSATION ........ .. ........ .... BUREAU OF MONITORING AND AUDIT : Index No. SELF-INSURANCE SECTION : Calendar No. RE-APPLICATION FOR SELF-INSURANCE BY PREVIOUSLY SELF-INSURED ENTITY WHICH RESTRUCTERED INSTRUCTIONS Plaintiff(s) -against- : JUDICIAL SUBPOENA : All information entered on this application must be typewritten and the application and all accompanying documents must be filed in duplicate to: Self-Insurance Section, P.O. Box 5497, Tallahassee, Florida 32314-5497. : All financial information submitted with this application must be prepared in accordance with United States Generally Accepted Accounting Principles. Three years of audited financial statements or pro forma financial : statements, reviewed by an independent Certified Public Accountant in accordance with Statement on Standards for Accountants Services on Prospective Financial Information, Financial Forecast and Projections, Defendant(s) : . . . . . . .must. .accompany. .this . application. . .All. .financial . information submitted with this application must be in the ... .......... .. ........... . ....... .. name entered on Line 1 below. The undersigned employer (hereinafter referred to as the applicant), an employer subject to the provisions of THE PEOPLE OF THE STATE OF NEW YORK hereby makes application for the status of a self-insurer in order to pay the Florida Workers' Compensation Law, TO compensation directly. In connection with such application, the applicant makes the following declarations for the purpose of enabling the Division of Workers' Compensation (hereinafter referred to as the Division) to make a finding of facts as to whether the applicant meets the qualifications for self-insurance established in Rule Chapter 4L-5, Florida Administrative Code. GREETINGS: The division will review this application and accompanying documents and will advise the applicant in writing of any additional requirements imposed by Rule Chapter 4L-5. All requirements shall be fulfilled prior to the WE COMMAND YOU, that all business The approval or laid aside, you and each of is governed by division's approval of this application. and excuses being denial of this application you attend beforeSections 120.57 he Honorable120.60, Florida Statutes and the applicable rules of procedure. In the event this application is, denied, the at the Court and County of applicant shall have located at to request an administrative hearing on the denial of the application in the right n room accordance the Sections 120.57 and, 20 , on with day of , Florida Statutes.in the requirements to self-insure are not met o'clock If all noon, and at any recessed 120.60, at or adjourned date, todays of the date of application, the division on the partthe the testify and give evidence as a witness in this action reserves of right to deny this application without within 30 prejudice. 1. Name of Applicant Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to he party 2. Applicant's Federal Employer Identification maximum penalty of $50 and all damages sustained as a on whose behalf this subpoena was issued for a Number esult of your failure to comply. 3. Address - Principal Office Witness, Honorable Court in County, 3a. , one of the Justices of the day of , 20 Telephone number (Attorney must sign above and type name below) 4. Attach a list of all subsidiary or affiliated companies which are to be included under the applicant's selfinsurance privilege. Indicate the percentage ownership of the applicant in each subsidiary or affiliated company. Include the address of each Florida location for each subsidiary or affiliated company. Attorney(s) for 5. Applicant is a (check one): corporation , partnership , individual proprietorship or other ______________ Attach proof that applicant or subsidiaries are registered Florida corporations. , Office and P.O. Address 6. Name of employee who will coordinate self-insurance program 6a. Title: 6b. Address if different from #3 above 6c. Telephone No.: Facsimile No.: E-Mail Address: Telephone number if different from #3a above Tel. No.: Mobile Form SI-1a American LegalNet, Inc. www.USCourtForms.com Page 1 of 3 COURT 7. Applicant's Classification COUNTY .OF. . . . . . . . .primary .Standard. Industrial . . . . . . . . . . Code ......... .. ...... ....... ........ : Index No. 8. Year business established . If a corporation, under laws of what state? 9. Attach a completed Certification of Servicing (Form SI-19). : Calendar No. : JUDICIAL past two(2) if 10. Attach a copy of at least your Plaintiff(s) current experience modification rating,SUBPOENAavailable. -against- : 11. Give the following estimated payroll information for your first 12 months of self-insurance. Provide the payroll classifications assigned to your operations using the classification system established by the National : Council on Compensation Insurance. : AMOUNT OF PAYROLL BY OCCUPATIONAL CLASSIFICATION Defendant(s) : ...................................................... No. of Employees Occupation Payroll FOR DIVISION USE ONLY Payroll Class. THE PEOPLE OF THE STATE OF NEW YORK Manual Annual Rate Premium Gross TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of Total Premium noon, and at any recessed $ _________________________ in room , on the day of , 20 , at o'clock in the or adjourned date, to testify and give evidence as a witness in this action on the part of the 12. If a corporation, attach a list of the name and residence of each corporate officer; if a partnership, the name and residence of each partner; if an individual proprietorship, the name and residence of the owner. 13. If a limited comply with this subpoena is of formation and duration court and will make you liable to Your failure to partnership, give the date punishable as a contempt of of partnership. the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of14. Isfailure to comply. subsidiary?_______ If so, give the name and address of parent company your the applicant a Witness, Honorable Court in County, , one of the Justices of the day of , 20 15. In consideration of the approval of this application, the applicant hereby expressly understands and agrees to the following: a. (Attorney bonds and and type insurance To maintain such cash security deposits or suretymust sign above excess name below) as required by the rules of the division. b. To abide by all provision of Chapter 440, Florida Statutes, the Florida Workers' Compensation Law Attorney(s) for and all rules of the division. c. That the privilege to self-insure may be revoked for cause at the discretion of the division as provided by Section 440.38, Florida Statutes. Office and P.O. Address d. To fully discharge by cash payments all amounts required to be paid by the provisions of the Workers' Compensation Law within the time periods prescribed by law. e. To pay to the division all assessments required by Chapter 440, Florida Statutes. Facsimile No.: f. To pay to the Florida Self-Insurers Guaranty Association, Inc. all assessments required by Section Mobile Tel. No.: 440.385, Florida Statutes and Plan of Operation of the Florida Self-Insurers Guaranty Association, Inc. American LegalNet, Inc. Page 2 of 3 Telephone No.: E-Mail Address: www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : g. Index No. That the self-insurance privilege extended upon approval of this application applies only to the applicant and such businesses or subsidiaries in which it has a majority ownership interest and which : Calendar No. are included on this application. h. JUDICIAL SUBPOENA That other businesses orPlaintiff(s) subsidiaries in which the applicant has majority ownership interest may be included under its self-insurance privilege upon written notification to the division and after -against: submitting such financial information and entering into indemnification agreements as the division may require. : : i. That the self-insurance privilege extended upon approval of this application will be revoked by the : division when the majority ownership interest of the applicant changes from that indicated by its application. That is, if the applicant is sold, merged, dissolved or otherwise changes its ownership Defendant(s) : . . . . . . . . . . . . . . . . interest .to. the .extent .that .the. financial. information upon which the self-insurance privilege was ...... . ... ..... ... .. ....... .... granted can no longer be used to determine the applicant's financial ability to pay compensation benefits promptly in accordance with the law. THE PEOPLE OF THE STATE OF NEW YORK I, _______________________________________________, certify that all businesses included under this application are in compliance with the coverage requirements of the workers' compensation law contained in Section 440.38(1), Florida Statutes and that all such businesses will remain in compliance with this section pending approval of this application. I further certify that all information contained in this application is true and GREETINGS: to the best of my knowledge. correct TO WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of Applicant in room , on the day of , 20 , at o'clock in the Name) and at any recessed noon, (Employer or adjourned date, to testify and give evidence as a witness in this action on the part of the By (Signature) Your failure to comply with this subpoena isTitle punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum Partner of $50 and all damages sustained as a (Owner, penalty or Corporate Officer) result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Form SI-1a American LegalNet, Inc. www.USCourtForms.com Page 3 of 3