INDUSTRIAL COMMISSION OF THE STATE OF IDAHO APPLICATION WORKERS' COMPENSATION SELF-INSURANCE Applicant: Parent Company: Main Office Address: Adjuster: Adjuster Address: Three-Year Payroll: 20 20 20 :$ :$ :$ 3-year average payroll $ Security Deposited: $___________________________ Type: ____________________________ Wholly-Owned Subsidiaries: NAME FEIN # LOCATION 1 2 3 4 5 6 7 8 9 10 The above-named applicant, a corporation, duly existing under the laws of the State of ______________ desiring to be fully qualified to self-insure in its workers' compensation liability pursuant to Section 72301, Idaho Code, and respectfully represents: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 1. That its previous three-year average annual Idaho payroll, not to include any subsidiary payroll, is in excess of $4,000,000. 2. That it has deposited security in a form and amount as described above. 3. That it has appointed the above-named resident claims adjuster and given it full claims authority as more fully evidenced by a copy of that authorization letter attached. 4. That its last annual statement of assets and liabilities is attached hereto. 5. That it will, at its own expense, keep on hand all forms which are or may be prescribed by the Commission for processing, service, and adjustment of claims and make available to employees such forms as it may require to initiate and perfect claims. 6. That it has delivered to the Idaho State Treasurer a power of attorney authorizing such officer, upon order of a court of competent jurisdiction or of the Industrial Commission, to sell such securities and any of them and disburse the proceeds thereof to any unpaid and deserving claims for which the securities have been deposited. 7. That it will make reports to the Commission as it may require. 8. That it will comply with the statutes of the State of Idaho and rules and regulations of the Industrial Commission to the end that payments of compensation shall be sure and certain and not unnecessarily delayed. DATED THIS ________ DAY OF ______________________________, 20_________. X Signature of Officer Print Name of Officer Title STATE OF On this __________ day of appeared COUNTY OF in the year 20____, before me personally (name of officer) known to me to be the person whose name is subscribed to the within instrument, and acknowledged to me that he executed the same. IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal, this day and year in this certificate first above written My commission expires Notary Public residing at IC 4006 American LegalNet, Inc. www.FormsWorkFlow.com