þ þ Applicant organization name þ Date of application þ Permit number (renewals only) hereby applies for the privilege of being a self-insurer under the Kansas Workers Compensation Act and submits the following report in support of said application.All questions must be answered; if not applicable, put N/AAttach additional sheets wherever needed. þ Individual Partnership Corporation Public Authority LLC þ þ þ þ þ þ Name/Title þ Business address þ þ þ þ þ þ þ þ Name þ Title þ Phone þ Address of responsible person (if different from item 1 above)6. Service company information a. Loss prevention services: (1) þ Name of service company (2) þ Address of service company (3) þ Phone (4) þ Contact person (5) þ Give details of services furnished by service company K-WC 120 (Rev. 11-15)APPLICATION FOR SELF-INSURANCEKANSAS DEPARTMENT OF LABOR þ Page 1 of 12www.dol.ks.govDIVISION OF WORKERS COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com b. Claims handling services: (1) þ Name of service company (2) þ Address of service company (3) þ Phone (4) þ Contact person (5) þ Give details of kinds of services that will be furnished by service company If you DO NOT plan to use an adjusting company, please explain on a separate attachment the plan you have for adjusting claims for your company. Such explanation should include the name of the person directly in charge of the adjusting activity. Explain what procedure you plan to follow in regard to investigating and adjusting claims and whether those individuals adjusting claims will be exclusively engaged in that activity.The Division of Workers Compensation may require the use of an adjusting company if we do not feel that your in-house adjusting procedure would be adequate to serve the injured workers.DO THE ABOVE 5. AND 6. (a) AND (b) HAVE A WORKING KNOWLEDGE OF THE KANSAS WORKERS COMPENSATION ACT? Yes No7. Safety program a. þ Person in charge c. When were premises last inspected? Inspecting agency8. Medical and hospital care a. Do you employ a full or part-time doctor? Yes No Name b. Name of provider to whom injured are normally sent:? c. Do you have a hospital in the plant? Yes No First aid room? Yes No Professional nurse on premises? Yes No Kansas Department of Labor Page 2 of 12 Application for Self-insuranceK-WC 120 (Rev. 11-15)DIVISION OF WORKERS COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com 9. Loss history (5 years) in State of Kansas (NEW PERMIT APPLICATIONS ONLY) Liability Period National Council on Compensation Insurance Gross þ Total þ Paid þ Experience þ þ þ þ þ þ þ þ þ þ þ þ þ þ W.C. þ Number of þ Estimated Annual þ Current þ Manual þ þ þ þ þ þ *Generally available from your insurance agent or excess carrier. Use the current approved Assigned Risk Rates.These rates are measurable for manual premium determination.Total estimated annual gross payroll: $ þ­ Total number of employees in Kansas: Total estimated manual premium: $11. For the state of Kansas, indicate the workers' estimated average weekly wage at your company (exclude clerical and executive wages): $ Kansas Department of Labor Page 3 of 12 Application for Self-insuranceK-WC 120 (Rev. 11-15) TotalsDIVISION OF WORKERS COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com þ þ þ þ þ þ a. b. Aggregate excess insurance þ Policy limit: þ þ Policy limit: þ $ þ þ þ þ Minimum loss fund: þ $ þ Estimated loss fund: þ $ þ Policy term: þ Policy term: þ þ Policy number: þ þ Policy number: þ Name of insurer: þ þ Name of insurer: þ c.Date self-insured authority to become effective (N/A for renewal): d.Excess insurance renewal date: 13. Do you have any owned, leased* or chartered aircraft? Yes No Does your excess policy cover this additional exposure? Yes No*Leased aircraft: one that is not owned by the applicant and made available for the use of the applicant under the termsof a rental or lease agreement for a period of not less than 30 consecutive days, and operated by someone other than anemployee of the owner or lessor of such aircraft.14. List the states or jurisdictions a. If you have ever been denied a self-insured permit or non-renewal in any state, please indicate the name of the stateand why you were not accepted or not renewed. þ þ þ þ þ (per occurrence) (per occurrence)STATUTORY Kansas Department of Labor Page 4 of 12 Application for Self-insuranceK-WC 120 (Rev. 11-15)DIVISION OF WORKERS COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com 15. Give the following totalsas a self-insurer. If unavailable on a state-by-state basis, combined totals may be given. Most Recent þ Calendar Year þ Total þ Total Medical Dates þ Average þ Unpaid þ Number of þ Total Annual þ Indemnity þ Medical þ (Reserves) þ State þ From þ To þ Employees þ Gross Payroll þ Paid* þ Paid* þ þTotal Indemnity Unpaid (Reserves) * Include current and ALL prior years ** þ Include current and ALL prior years for payment in future by self-insured and not by insurance carrier. Kansas Department of Labor Page 5 of 12 Application for Self-insuranceK-WC 120 (Rev. 11-15)DIVISION OF WORKERS COMPENSATION16. Give the following information(Use a separate page for full details.) Total Estimated Cost Date þ Number of þ Medical of þ Employees þ Facts of Loss, Type of Injury or Disease þ Indemnity þ Expense þ Total þ þ þ þ þ American LegalNet, Inc. www.FormsWorkFlow.com þ þ þ þ þ Yes No If yes, describe 18. Are there any actual or potential occupational disease exposures involved in applicant's operations? Yes No These may include dust, gases or fumes, chemicals and toxic substances, extreme changes of temperature, noises orpressure, physical vibrations, constant pressure and use, physical movement in constant repetition or radioactive rays,infections and organisms, bloodborne pathogens or radiation. If yes, describe 19. Furnish information on any substantial or unusual changes (increase or decrease) in operations in Kansas that are þ þ þ þ þ þ þ þ þ þ þ þ Longshoremen and Harbor Workers' Act? Yes No Jones Act? Yes No Federal Employers' Liability Act? Yes No If yes, explain21. a. þ If the employer is rated by Standard & Poor or Dun & Bradstreet, show the latest ratings, INCLUDING the date ofthe rating: (Ultimate Parent rating if application is submitted by subsidiary). Standard & Poor þ Dated: Dun & Bradstreet þ Dated: Other þ þ Dated: þ þ þ þ þ þ Ultimate Parent SIC if application is submitted by subsidiary.) manufacturing, transportation, communications, utilities, wholesale trade, retail trade, services, etc. In Kansas, theSIC Code is assigned by Kansas Department of Labor (KDOL) Labor Market Information Services, under contractwith the Federal Bureau of Labor Statistics. Kansas Department of Labor Page 6 of 12 Application for Self-insuranceK-WC 120 (Rev. 11-15)DIVISION OF WORKERS COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com þ þ þ þ þ 225 List parents of applicant in hierarchical order, beginning with ULTIMATE PARENT COMPANY regardless of Kansas operation.225 225 Place an arrow () in column (1) showing Applicant's direct parent company.225 List % of voting stock by each corporation's direct parent, and show whether corporation is a parent or subsidiary of the applicant. TOPPARENT Parent Column 1 þ Legal Name of Corporation þ Address(es) of all Kansas Locations þ ( % ) þ or Sub. Kansas Department of Labor Page 7 of 12 Application for Self-insuranceK-WC 120 (Rev. 11-15)DIVISION OF WORKERS COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com þ þ þ þ Year List each Kansas operation of the applicant. (Do not list excess insurance on this chart.) Kansas Employees þ No. Cases þ To be Name of Operating Unit þ Operation Type þ Entered þ Self-Ins.** and Location þ Main Products, þ Average þ Annual Gross þ on OSHA (Include Street Address) þ Services, Activities þ Number þ Payroll þ 300 log þ Yes þ No $þ $ þ $$$ $ $þ $ $$ TOTALS**If no: þ Full name of insurance company Policy number Policy ending date Does this unit have separate employees and payrolls? Yes No24.EXCESS INSURANCE:List all excess policies that cover Kansas Workers Compensation Insurance (Check which type of excess in force). Aggregate Other þ Upper Limit of Policy Period Insurance Co