Initial Application by Employer for Authority to Pay Compensation Etc., Directly SIDN Application Number Instructions · Please answer all questions. If not applicable, use symbol N/A. · Please use SIDN number for all correspondence and inquiries until assigned a self-insured risk number. Company Information Present state-fund risk number Federal ID number Address State Nine digit ZIP code State of incorporation Date of incorporation Name Address Designation Complete this Section if Applicant is a Subsidiary Ultimate USA parent federal ID number State of incorporation Date of incorporation % Please attach a detailed organizational chart, if applicable SI-6 American LegalNet, Inc. www.FormsWorkFlow.com Additional Applicant Information If yes, please complete information below. Risk number All Part of business Manual number Manual description Number of Ohio employees Financial Information Excess Workers' Compensation Insurance Does your company intend to carry excess workers' compensation insurance? Name of carrier: Name of agent: Policy number: Limit of indemnity: Self-insured retention: Telephone number: ( ) Yes No American LegalNet, Inc. www.FormsWorkFlow.com Instructions · · · Information Update Request This form completed by: Name and title Salaried employees BWC USE ONLY Salaried employees BWC USE ONLY Salaried employees BWC USE ONLY Additional locations on reverse side. SI-6 PG. 2 American LegalNet, Inc. www.FormsWorkFlow.com Important notice: Salaried employees BWC USE ONLY Salaried employees BWC USE ONLY Salaried employees BWC USE ONLY Salaried employees BWC USE ONLY American LegalNet, Inc. www.FormsWorkFlow.com