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Self-Insured Employers Application To Add A Subsidiary Form. This is a Maryland form and can be use in Financial Reporting Workers Compensation.
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Tags: Self-Insured Employers Application To Add A Subsidiary, A-05S, Maryland Workers Compensation, Financial Reporting
STATE OF MARYLAND
WORKERS’ COMPENSATION COMMISSION
10 East Baltimore Street · Baltimore · Maryland · 21202
(410) 864-5100 · (800) 492- 0479
web - http://www.wcc.state.md.us
SELF-INSURED EMPLOYER’S APPLICATION TO ADD a SUBSIDIARY
Part I - General
a. Approved Self-insured Employer:
Name:
Address: Street
City
Telephone:
Contact Person:
Email address:
Federal ID Number:
State
ZIP Code
FAX:
b. Maryland Claims Administrator (Not the Attorney of Record):
Company name:
Address: Street
City
Telephone:
Representative Name:
Email address:
State
ZIP Code
FAX:
c. Applicant Subsidiary
Subsidiary
Name:
Home Office Address: Street
City
Telephone:
Date Acquired:
Contact Person:
Email address:
Maryland Address: Street
City
Telephone No:
Form A-05S (rev 12/2006)
Division
Affiliate
Other (explain)
Federal ID Numbe r:
State
ZIP Code
FAX:
Date of Incorporation:
Requested Effective Date:
State
ZIP Code
FAX:
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STATE OF MARYLAND
WORKERS’ COMPENSATION COMMISSION
10 East Baltimore Street · Baltimore · Maryland · 21202
(410) 864-5100 · (800) 492- 0479
web - http://www.wcc.state.md.us
Part II - Employment and Related Data
Principal workers compensation classification of employees :
Please provide the following information for the subsidiary for each year of the last three years prior to filing this
application:
Dates
From
To
No. of
Employees
Annual
Maryland
Payroll
Experience
Modifier
Workers’
Compensation
Premiums
For the last 12 months prior to filing this application, please provide the following for the subsidiary:
Classes of Employees
(NCCI Codes)
No. of Employees (in each class)
Annual Payroll
(for each class)
(If additional space is required, please attach a separate sheet clearly marking the name of the self-insured employer
and the name of the subsidiary, affiliate or division.)
No. of Accidents (SF-1issued):
Form A-05S (rev 12/2006)
during the last 12-month period ending:
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STATE OF MARYLAND
WORKERS’ COMPENSATION COMMISSION
10 East Baltimore Street · Baltimore · Maryland · 21202
(410) 864-5100 · (800) 492- 0479
web - http://www.wcc.state.md.us
Total claims incurred, including medical and indemnity, both paid and additions to reserve, for the following:
Period Covered
The last 12 month period
TO
FROM
AMOUNT
Prior 12 months
Second Prior 12 months
Part III - Certification
I certify that to the best of my knowledge and belief, the information contained in this application
is true and correct.
Name of Approved Self-Insurer:
By: _______________________________________
(Signature)
Title:
NOTE:
(Printed Name)
Date:
A. If the unit being added to your self-insurance program is a subsidiary or an affiliate you must
complete a Parental Guarantee & Board Resolution (MD WCC form A-04, 9/2006) [see our web
FORMS page at http://www.wcc.state.md.us for forms and additional information]. This is not
required for a division. County and municipal governments adding units are assumed to guarantee
all entities included in their self-insurance programs.
B. Provide the three most current years of audited financial statements for the subsidiary.
C. A $250.00 non-refundable fee, check made payable to MD Workers’ Compensation
Commission., must accompany this application.
Form A-05S (rev 12/2006)
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