Application to write Longshore Insurance U.S. Department of Labor Employment Standards Administration Office of Workers' Compensation Programs The Applicant hereby requests that the Office of Worker's Compensation Programs grant permission for the Applicant to become authorized to write insurance under the Longshore Act and its extensions in accordance with Section 32 of the Longshore and Harbor Workers' Compensation Act (33 USC 932) in regard to the insurance carrier's obligations under the Compensation Act checked in item 1. The declarations made in this application are for the purpose of enabling the Office of Workers' Compensation Programs to make a finding of facts as to whether the Applicant possesses sufficient ability to render certain the payment of compensation, the furnishing of medical services and supplies to injured employees, and the payment of compensation for death in accordance with the provisions of the Act checked in item 1. The Applicant agrees to make and maintain a deposit of securities with a Federal Reserve Bank or a Letter of Credit from an approved financial institution or (option to be indicated in item 6) which shall be in an amount determined by the Office and subject to the order of the Office. The Applicant further agrees to abide by all the rules and regulations administered by the Office pertaining to the Longshore and Harbor Workers' Compensation Act (33 USC 901) or any of the extensions of the Act checked in item 1. INSTRUCTIONS: All items are to be completed and/all required documentation must be submitted. If the answer to any item requires more space than provided, please attach a separate sheet and identify the item you are answering. Information contained herein shall not be open to public inspection. The application must be accompanied by: (1) A letter signed by a corporate officer requesting authority to write coverage, including a statement of the company's underwriting intentions, (2) A copy of the Statutory Annual Statement for the three most recent years, (3) A copy of the company's Articles of Incorporation, (4) A copy of the Corporate by-laws, (5) A copy of the Certificate of Authority issued by a State insurance department granting authority to write workers' compensation insurance, (6) A copy of the most recent examination report of the company by a State Insurance Commissioner's office, (7) A copy of the most recent report of the company's NAIC's IRIS financial ratios, (8) A copy of the forms of policies and endorsements that will be used. At the present time, five years experience writing workers compensation coverage and a rating of ''B+'' or higher by the A. M. Best Company is required for authorization, along with satisfaction of the above documentary requirements. The application should be mailed to: U.S. Department of Labor, Employment Standards Administration, Office of Workers' Compensation Programs, DLHWC, Room C-4315, 200 Constitution Avenue, NW, Washington, DC 20210. 1. Check only one of the Acts. if you wish to be authorized under more than one Act, file a separate application for each. A. Longshore and Harbor Workers' Compensation Act (33 USC 901) C. Defense Base Act (42 USC 1651) B. Nonappropriated Fund Instrumentalities Act (5 USC 8171) D. Outer Continental Shelf Lands Act (43 USC 1331) 2. Name and Address (Principal Office) of Applicant 3. If you are now authorized to write insurance under any state workers' compensation program, please advise of those states and the type of coverage for which you are authorized. 4. Name of Company President 5. Name of Company Vice President 6. Name of Company Treasurer 7. Name of Company Secretary 8. I certify that I am an official of the above named applicant, duly authorized to file this application, that I have carefully examined the foregoing statements and the facts herein are true, 9. Title CORPORATE SEAL Signature 10. Date of This Application DO NOT WRITE IN THE ITEMS BELOW FORM LS-272 11. Date Application Received 12. OWCP Certification No authorization for insurance will be approved unless a complete application form has been received. (33 USC 933) [20 CFR 703]. American LegalNet, Inc. www.FormsWorkflow.com