EL-I 4/1/97 EMPLOYEE LEASING COMPANY REGISTRATION FORM (A) Lessor Information - (Employee Leasing Company) 1. Company: ____________________________________________________________________________ 2. Address: ____________________________________________________________________________ Principal Place of Business ___________________________________________________________________________ ______________________________________________Telephone No.________________ Name 3. KY. Address:__________________________________________________________________________ __ ______________________________________________Telephone No.________________ 4. Type of Entity:_______________________________________________________________________ Proprietorship, Partnership, Corporation 5. FEIN or SSN:__________________________________________________________________________ 6. Parent or Holding Company:____________________________________________________________ Name ___________________________________________________________________ Address ___________________________________________________________________ ___________________________________________________________________ 7. List, by jurisdiction, of each and every name Lessor has operated under in preceding five (5) years including any alternative names and names of predecessors or successors (use additional sheets, if necessary): __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 8. List of each and every person or entity currently owning a five percent (5\) or greater interest in the employee leasing company: ___________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 9. List of each and every person or entity formerly owning a five percent (5\) or greater interest in the employee leasing company or its predecessors, successors or alter egos in the preceding five (5) years: _____________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ (B) Current Workers' Compensation Insurance Information 1. Carrier Name:_____________________________________________________________________ 2. Policy Number:____________________________________________________________________ 3. Policy Period:____________________________________________________________ 4. Name of insured as it appears on policy:__________________________________________ __________________________________________________________________________________ (C) Past Workers' Compensation Insurance Information 1. The following workers' compensation policies issued to the employee leasing company or its predecessor(s) have been cancelled or non-renewed within the last five (5) years (use additional sheets, if necessary): American LegalNet, Inc. www.USCourtForms.com Carrier:_____________________________________________________________________________ Policy or Certificate Number_________________________________________________________ Date of cancellation_________________________________________________________________ Reason for cancellation:_____________________________________________________________ 2. The following Affidavit must be executed by the Chief Executive Officer of t he employee leasing company if no such cancellation or non-renewal has occurred. AFFIDAVIT Comes now the affiant,_______________________________ , and after having being duly sworn states as follows: 1. My names is________________________________________ and I am the Chief Executive Officer of_________________________________________, an employee leasing company. 2. During the five (5) years preceding the date of this application neither the applicant nor any of its predecessors, successors or alter egos has had a workers' compensation policy cancelled or non-renewed. 3. Further affiant saith naught. _______________________________________________ CHIEF EXECUTIVE OFFICER OF APPLICANT STATE OF___________________ COUNTY OF__________________ Acknowledged, subscribed and sworn to before me by_________________________________, This____day of______________, 20___. _________________________________________ NOTARY PUBLIC MY COMMISSION EXPIRES:__________________________, 20____. (D) CERTIFICATION I do hereby certify that I am the duly authorized agent of a________________ _________________, an employee leasing company; that the information contained in this application is true; and that the applicant will comply with the mandate of 803KAR 25:230 to immediately notify the Commissioner of the Department of Workers' Claims of any changes in the information provided in this application, and to provide information regarding workers' compensation coverage of leased employees within ninety (90) days of approval on Form EL-2. DATE __________________________ Address__________________________ __________________________ __________________________ Telephone No.____________________ NAME(typed) _______________________________ SIGNATURE___________________________________ INSTRUCTIONS This application is to be filed with the Division of Security and Compliance, Kentucky Office of Workers' Claims, Prevention Park, 657 Chamberlin Ave. Frankfort, KY 40601. A duplicate copy will be returned as evidence of registration. NOTICE: Falsification of this application constitutes a criminal offense (KRS 523.1001. Violation of the employee leasing provisions of Kentucky law can result in civil and criminal penalties (KRS 342.990). American LegalNet, Inc. www.USCourtForms.com