MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS APPLICATION FOR MEMBERSHIP IN THE _________________________________________________________________________________________________ (Trust Fund Name) Name & dba ______________________________________________________________________________________ Corporation (Number) Co-Partnership Individual Mailing Address ___________________________________________________________________________________ (Street) (City) (State) (ZIP Code) Location Address ___________________________________________________________________________________ (Number) (Street) (City) (State) (ZIP Code) Nature of business ___________________________________________ FEIN Number __________________________ List partners or corporate officers: ______________________________________________________________________________________________ (Name) (Name) (Name) (Name) (Title) (Title) (Title) (Title) ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Insurance Coverage is now carried by: __________________________________________________________________ We hereby formally apply for continuing membership for workers' compensation self-insurance coverage in the abovenamed Trust, to be effective 12:01 A.M. ______________________, ____________, and, if accepted by its duly author ized representative, do hereby constitute and appoint (if applicable, Service Company) ____________________________ _______________________________________________________________ to act as Administrators of the Trust and as our agents-in-fact in all matters relating to the Workers' Compensation Law. We further agree as follows: (a) To accept and be bound by the provisions of the Missouri Workers' Compensation Act (b) That, by this reference, the terms and provisions of the Indemnity Agreement and/or Amendments thereto filed or which may hereafter be filed with the Missouri Division of Workers' Compensation are hereby adopted, approved, ratified and confirmed by us; and further, we agree to assume all of the obligations set forth therein, including our joint and several liabilities for payment of any lawful awards against any member of the trust; and in the event we fail to pay any premium or lawful assessment within thirty (30) days of the date the same shall become due, we will pay all costs of the collection thereof, including reasonable attorneys' fees (c) To abide by the rules and regulations of the trustees of the trust and to conform to the terms of the agreements they may enter into with any authorized service company as long as we remain a member of the trust (d) That, in the event of any changes in corporate structure, or in legal entity, or if any locations are to be added to or deleted from this coverage, we agree to immediately notify (Name of the Trust Fund or Service Company) _________________________________________________________________________________________ (Address) ________________________________________________________________________________. WC-81B (08-11) AI American LegalNet, Inc. www.FormsWorkFlow.com That should we desire to cancel our coverage, we will give notice in accordance with the terms and conditions established by the trust (f) That coverage under this membership shall be for Missouri operations only (g) That the Wage Declaration Schedule and/or Certificates, when completed and returned to us by (Service Company) _______________________________________________________________________________, become a part of this agreement. ________________________________________________ (Typed Name of Applicant) (e) _____________________________________________ (Title) (Owner, Partner, Corporate Officer) ________________________________________________ (Signature of Applicant) WITNESSES: (1) ________________________________________ (Typed Name) ________________________________________ (Signature) ________________________________________ (Address) (2) ________________________________________ (Typed Name) ________________________________________ (Signature) ________________________________________ (Address) ________________________________________________ (Corporate President) ________________________________________________ (Date) The above applicant is a member of ____________________________________________________________________ and is hereby approved for membership in this trust, and coverage is effective the __________________________ day of ______________________________, ___________. Signed this ______ day of _______________, ________ By: __________________________________________ (Fund Administrator or Trustee) WC-81B-2 (08-11) AI American LegalNet, Inc. www.FormsWorkFlow.com _________________________________________________________________________________________________ Name of Trust Fund Effective ____________________ to ____________________ Member Name _____________________________________________________________________________________ Address ______________________________________________ City________________ State_______ ZIP__________ Present coverage _________________________________________ No. Locations ________ No. Employees ________ Own or operate aircraft? __________ Details _____________________________________________________________ Premium Estimate by Class Code Classification Estimated Next Year Payroll Rate Per $100 Estimated Premium _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _________ __________________________ _________ __________________________ _________ __________________________ _________ __________________________ _________ __________________________ _________ __________________________ _________ __________________________ _________ __________________________ _________ __________________________ _________ __________________________ ____________________ _____________ ____________________ _____________ ____________________ _____________ ____________________ _____________ ____________________ _____________ ____________________ _____________ ____________________ _________