State of New York WORKERS' COMPENSATION BOARD INITIAL APPLICATION FOR LICENSE TO APPEAR ON BEHALF OF, OR REPRESENT, CARRIERS AND/OR SELF-INSURERS Under Section 50 3-b or 50 3-d of the Workers' Compensation Law and Rules with Respect to Granting Licenses to Representatives of Carriers and/or Self-Insurers Application is made under (CHECK ONE): Section 50 3-b Section 50 3-d If application is made for a license on behalf of a corporation, separate forms must be filled out and submitted by the president/CEO, the secretary, and the treasurer. If application is made on behalf of a partnership, separate forms must be filled out and submitted by each partner. Applicant's failure to disclose fully and accurately any fact or information called for by any question may result in the denial of the application for a license or, if applicant shall have been licensed before the discovery thereof, in the revocation of his/her license. 1. Name of applicant/organization Type of organization: individual partnership corporation other (specify) If corporation, attach copy of filing receipt from Secretary of State and give corporate Federal Employer Identification Number_______________________________. (See Privacy Notification on Page 4. If corporation has no Federal Employer ID Number, explain on page 4.) Has any other name been used? Yes No If Yes, state other names: Business address Business telephone number________________________Fax number__________________________ 1a. Type of claims to be administered: workers' compensation disability benefits both 2. Name and home addresses of individual, partners, or officers and directors of corporation: (attach list if more than three) Name Home Address Title 3. Attach list of principal stockholders (all those owning at least 20% of corporation's stock) and indicate percentage of stock owned by each. Each principal stockholder must complete Form OC-403.3 to be submitted with application. See copy attached--photocopy if additional copies are needed. 4. The following named persons will appear before the Board on my/our behalf when authorized. I agree to advise the Board of any changes and to surrender authorization cards that become invalid. Attach completed Form OC-403.2 for each employee listed. 5. State reason for making this application. New applicants list any prospective self-insurer and carrier accounts; if renewal, list all self-insureds and carriers represented by licensee within the last year. OC-403.1 (7-15) Page 1 American LegalNet, Inc. www.FormsWorkFlow.com PERSONAL HISTORY OF INDIVIDUAL, PARTNER OR QUALIFYING OFFICER Name__________________________________________ Title_______________________________ Social Security No._____________________ (See Privacy Notification on Page 4. If you have no Social Security Number, explain on Page 4.) 6. Business or occupation during past five years: (Give present business first.) From To Employer Business Address Salary 7. Are you over 18 years of age? Yes No Citizenship If naturalized, give date and place of naturalization: If permanent resident alien, give Alien Registration No. issuance of Alien Registration Card 8. Elementary school:___________________________________________ Graduate: 9. High school/equivalent________________________________________ Graduate: 10. College, university or technical schools attended: School From To and date of Yes Yes No No Degree 11. Have you ever been disbarred or had revoked for cause any license, certificate, permit or any other authorization to practice in any trade or profession? Yes No If Yes, give details: 12. Have you ever been convicted of a crime? Yes No If Yes, state when and give details: Are there any criminal charges now pending against you? Yes No If Yes, give details: 13. Have you ever acted as representative for any self-insured employer and/or insurance carrier in connection with workers' compensation claims? Yes No If Yes, give details, setting forth the arrangement under which you represented the self-insurer or carrier: 14. Do you have any arrangement with any health care providers in order to facilitate handling of workers' compensation claims? Yes No If Yes, give details: OC-403.1 (7-15) Page 2 American LegalNet, Inc. www.FormsWorkFlow.com 15. Have you any arrangement at the present time with any self-insured employers and/or insurance companies to represent them in connection with workers' compensation or disability benefits claims? Yes No If Yes, give details, including a list of all clients in this category. QUESTION 16 IS TO BE ANSWERED ONLY BY APPLICANTS UNDER SECTION 50-3d 16. Is the applicant organization a: subsidiary of insurance company affiliate insurance company of insurance company other (explain) If you are an insurance company, are you authorized to write workers' compensation insurance in New York State? Yes No If you are an affiliate, explain relationship I hereby authorize duly designated employees of the Workers' Compensation Board to make inquiry into and obtain disclosure of any information required to obtain verification of any statement made in this application; and I hereby agree that in the event the Board issues a license to me to represent self-insurers under Section 50 3-b or 50 3-d of the Workers' Compensation Law, I shall practice in accordance with the Law and Board Rules and Regulations established for licensed representatives. Name of Organization ) ss: County of ____________________) State of New York Signature and Title of Qualifying Officer Signature of Individual, Partner or Officer whose personal history is listed _______________________________________________, being duly sworn, deposes and says that I am the applicant; that I have duly read and signed the foregoing application; that all the matters contained herein are true, excepting as to such matters therein stated to be alleged on information and belief and those matters I believe to be true. Sworn to before me this ________day of ______________20___ _________________________________ Notary Public TO BE COMPLETED BY CORPORATE APPLICANTS ONLY __________________________________________ Signature of Individual, Partner or Officer State of New York ) City of_______________________ ) ss: County of ____________________) Affix Corporate Seal Here On this ____________day of _____________________________20 ____, before me personally came______________ ____________________________________to me known, who, being by me duly sworn, did depose and say that (s)he resides