WC-131 APPLICATION FOR PERMIT TO WRITE INSURANCE GEORGIA STATE BOARD OF WORKERS' COMPENSATION APPLICATION FOR PERMIT TO WRITE INSURANCE In conformity with Title 34, Section 34-9-131 of the Code of Georgia, it is hereby represented that the undersigned applicant has heretofore been licensed by the Insurance Commissioner of Georgia to write workers regulating insurance companies, under the provisions of the Georgia Workers Compensation Act. Send this form, accompanied by current GA Certificate of Auth -1299. Pursuant to the Code 34-9handling of claims or shall designate an agent located in the State of Georgia who shall be authorized to execute instruments for the payment of compensation. SECTION A. CORPORATE OFFICE (Corporate Officer Responsible for Regulatory Issues) Name of Carrier (As it appears on Certificate of Authority) FEIN # Address City Contact Person State Title Zip Code Toll Free Phone No. Plus Extension Primary E-mail Address for Licensure/Assessment SECTION B. CLAIMS HANDLING Name of TPA / Servicing Agent Contact Person Mailing Address City Phone Number and Ext E-mail Address State Zip Code SECTION C. (If Section A and B are locations outside the State of Georgia, Section C must be completed.) GEORGIA AGENT MUST be located in Georgia and MUST be able to execute payment/have check writing authority. Company Contact Person Mailing Address City Phone Number and Ext E-mail Address State Zip Code Compensation Act as embodied in title 34 of the Code of Georgia of 1982, as amended. Signed This Day of , 20___. Name of Company / Person Completing this application Type or Print Name Signature Phone Number and Ext E-mail Address AT 404-651-7839 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-131 REVISION . 07/2011 131 APPLICATION FOR PERMIT TO WRITE INSURANCE American LegalNet, Inc. www.FormsWorkFlow.com