Form SI Group Page 1 of 3 Rev. 0 1915 NORTH STILES AVENUE OKLAHOMA CITY, OK 73105 (405)522-3222 or In-State Toll Free (855) 291-3612 APPLICATION FOR GROUP SELF INSURANCE ASSOCIATION PERMIT Date The undersigned, a group of employers subject to the provisions of the Administrative Workers' Compensation Act, hereby applies for permission to act as a group self insurance association. To enable the Workers' Compensation Commission to determine the applicant, said applicant hereby states the following: 1.Group Name 2.Desired effective date (application should be submitted 60 days in advance) 3.Group # (if a renewal applicant) 4.Name of Sponsoring Trade Association, if any 5.Nature of business of members (common interest) 6.Name, address, phone number & e-mail address of Administrator 7.Name, address, phone number & e-mail address of Chairman 8.Name, address, phone number & e-mail address of Third Party Administrator for claims 9.Name, address, phone number & e-mail address of Third Party Administrator for other functions (accounting, marketing, etc.) American LegalNet, Inc. www.FormsWorkFlow.com Form SI Group Page 2 of 3 Rev. 0 10.Name, address, phone number and e-mail address of Auditor 11.Name, address, phone number and e-mail address of Actuary 12.Please include the following items with the application:a.A nonrefundable $1,000 application b.The following items, bound in a hardcover notebook:1)attorney.2)The estimated standard and discounted premium each association member will pay during thefirst/next fiscal year of the association.3)A listing of the type, amount, and eligibility requirements of discounts available for the associationmembers, including scheduled discounts.4)Projected expenses for the association for the first/next fiscal year, in dollar amount and apercentage of the standard premium to be generated.5)Underwriting guidelines that are used by the association.6)A -laws and any other governing instruments.7) and administrator.8)A copy of the contract(s) between the association and it TPA(s).9)A copy of all fidelity bonds and errors and omissions policies secured by the association, itsadministrator, its TPA(s), and other organizations providing services to the association.10)A copy of all marketing materials used, or to be used, by the association.11)compensation rates to be charged to its members, broken down by classificationcode.12)For new applicants:a)An executed copy of the application of each employer for membership in the association,including:i)The indemnity agreement and power of attorney executed by the employer;ii)The affidavit of acknowledgment of joint and several liability executed by the employer;iii)The employercurrent balance sheet.b)A pro forma financial statement of the association, showing the estimated revenues andexpenses for the first fiscal year of the association.c)A statement of the collective worth of the members of the association.d)The e)Properly executed biographical affidavits for the initial supervisory board and administrator.13)For renewal applicants:a)and all current actuarial reports.b)An attestation from the administrator or chairman that the collective net worth of the membersof the association exceeds Two Million Dollars ($2,000,000.00).c)A copy of the associations specific and aggregate excess insurance binders for the next fiscalyear, and copies of the policies for the current year.d)Copies of the minutes of all board meetings held during the current year.e)A list of the premiums paid and losses incurred by each member of the association during thecurrent fiscal year. American LegalNet, Inc. www.FormsWorkFlow.com Form SI Group Rev. 0 f)Affidavit from the chairman that the association is and has been in full compliance with the rulesof the Commission during the current fiscal year.g)Confirmation that proof of coverage filings have been made with NCCI.h)A listing of investments currently held by the association. 13.In consideration of the approval of this application, the applicant hereby expressly agrees to comply with all Administrative material false statement or representation, who willfully and knowingly omits or conceals any material information, or who employs any device, scheme, or artifice, or who aids and abets any person for the purpose by imprisonment, a fine or both. I declare under penalty of perjury that I have examined this application and all statements contained herein, and to the best of my knowledge and belief, they are true, correct and complete. Signed this day of , 20. Signature of a Member of the Board of Directors Signature of the Administrator or a Member of the Board of Directors (NOTE: the persons signing MUST be authorized to bind the Employer to the agreements contained herein) Print Name of Board Member Print Name of Administrator or Board Member Title of Board Member Title of Administrator or Board Member Mailing Address Mailing Address Street Address, if different from mailing Street Address, if different from mailing City State Zip City State Zip Email Address of Board Member Email Address of Administrator or Board Member Telephone Number of Board Member Telephone Number of Administrator or Board Member Send application to: COMMISSION SERVICES DIVISION 1915 NORTH STILES AVENUE, SUITE 231 OKLAHOMA CITY, OK 73105 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com