EL-2 4/1/97 LESSEE INFORMATION FORM 1. Employee Leasing Company Name:________________________________________________________ 2. Lessee Name:__________________________________________________________________________ 3. DBA:_________________________________________________________________________________ 4. Principal Address:_______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 5. KY. Address (if applicable):________________________________________________________________ ___________________________________________________________ ___________________________________________________________ 6. FEIN OR SSN:__________________________________________________________________________ 7. Type of Entity: Proprietorship - Partnership - Corporation ___________________________________________________________________ 8. Effective date of workers' compensation coverage under employee leasing company:___________________ Policy No:________________________ issued by:_____________________________________________ 9. Termination of coverage date:_______________________________________________________________ INSTRUCTIONS This information page must be completed for every Kentucky Lessee whose workers' compensation insurance coverage for leased employees, as required by KRS342.340 and KRS 342.640, is provided by an insurance policy in the name of the Employee Leasing Company or related entity. The completed form(s) must be filed wjthin ninety (90) days of initial registration of the Employee Leasing Company and updated every six (6) months. Filing shall be perfected upon receipt at the following address: Division of Security & Compliance, Kentucky Office of Workers’ Claims, Prevention Park, 657 Chamberlin Ave., Frankfort, KY 40601. American LegalNet, Inc. www.USCourtForms.com