MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS APPLICATION FOR GROUP SELF-INSURANCE (To be executed and sworn to in triplicate) 3315 West Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 ALL INFORMATION CALLED FOR ON APPLICATION MUST BE IN TYPEWRITTEN FORM The undersigned Group Fund hereby makes application to carry its own liability without insurance as provided in the Missouri Workers' Compensation Law. In connection with such application it makes the following declaration for the purpose of enabling the Division of Workers' Compensation (DWC) to determine whether it possesses sufficient financial ability to render certain the payment of compensation which its employees and their dependents may be entitled to under the Missouri Workers' Compensation Law. Applicant hereby agrees that if this application be approved, such approval shall be subject to its furnishing such security as may be required by the DWC. Applicant further agrees to abide by all of the provisions of the Missouri Workers' Compensation Law and by the rules governing self-insurers under said law. ___________________________________________________________________________________________________________ (Effective Date) Applicant Group Fund (Official Name) 1. Address of Principal Office ______________________________________________________________________________ (Number) (Street) (City) (State) (ZIP Code) 2. Trustees Name _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Business Address __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ 3. Administrator __________________________________________________________________________________________ (Name) (Address) (Telephone Number) 4. Claims Program ________________________________________________________________________________________ (Name of Service Company) (Address) (Telephone Number) 5. Safety Program _________________________________________________________________________________________ (Name of Person Responsible) (Telephone Number) WC-81A (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com 6. Total Number of Employer Members ____________ (Attach List of Members) Total Estimated Premium ________________________ Group Experience Mod. __________________________ Excess Carrier ___________________________________ Policy Number __________________________________ Standard Premium _______________________________ Estimated Collectible Premium After Discount __________________________ 7. Applicant will Submit: A. Specific Excess Insurance Policy Limit Retention Term B. $____________________ $____________________ _______________ to _______________ D. C. Surety Bond Amount Bond Number $____________________ ____________________ Carrier ____________________________________ Fidelity Bond Amount Bond Number $____________________ ____________________ Aggregate Excess Insurance Policy Limit Term $____________________ _______________ to _______________ Loss Fund ______% of collectible premium after any discount Loss Fund Loss Limit Est. Min. Loss Fund $____________________ $____________________ $____________________ Carrier ____________________________________ In consideration of the privilege of being a self-insurer, we hereby agree: a. That we will discharge our liability for compensation to injured employees or their dependents in accordance with the requirements of the Workers' Compensation Act of the State of Missouri. That we will follow the Administrative Rules of the DWC and any additional conditions imposed by the Division as part of our approval. That we will promptly furnish all reports to the DWC which it may lawfully require under the Workers' Compensation Act. That we will notify the DWC promptly of any unfavorable turn in our financial condition which might reasonably reduce our ability to carry our own risk under the Workers' Compensation Act. b. c. d. We affirm all information submitted as being true. __________________________________________________ (Group Fund) by __________________________________________________ (Official Title) Date ______________________________ WC-81A-2 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com _________________________________________________________________________________________________ Name of Group Fund Effective ____________________ to ____________________ Amount of Payroll by Classification for Current Year of Group Fund Code ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ Classification __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Payroll _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ Manual Premium _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ TOTALS _____________________ Standard Premium Loss History Experience Date _____________________ year _____________________ year _____________________ year _____________________ year _____________________ year Gross P