COMMONWEALTH OF VIRGINIA Page 1 of 7 COMMONWEALTH OF VIRGINIA VIRGINIA WORKERS' COMPENSATION COMMISSION 1000 DMV DRIVE, RICHMOND VA 23220 Employer's Application for Individual Self-Insurance Under the Virginia Workers' Compensation Act Note - Under rule, adopted by the Commission, November 20, 1918, all information given in this application is strictly confidential. To the Virginia Workers' Compensation Commission: The undersigned, an employer subject to the provisions of the Virginia Workers' Compensation Act, hereby applies for the privilege of being exempt from the necessity of insuring the payment of compensation provided in that act, and submits the following facts under oath to the Virginia Workers' Compensation Commission to enable it to determine if sufficient financial ability exists to render certain the payment of such compensation: 1. Applicant: Name: ______________________________________________________________ Address: ______________________________________________________________ City, State, Zip: ______________________________________________________________ 2. Corporate information: 2a. The applicant is a: ______________________________________________________________ (Sole proprietorship, partnership, limited partnership, corporation, trustee.) Federal tax identification number (FEIN): 2b. If a corporation, indicate the State and date of the charter: State: __________ 2c. ____-__________ Date: __________ If a subsidiary, indicate the name and address of the parent company Name: Address: ______________________________________________________________ City, State, Zip: 2d. ______________________________________________________________ ______________________________________________________________ If a limited partnership, give date of formation and duration: Date: __________ 2e. Duration: __________ List the names of all subsidiaries and/or operating entities doing business in Virginia: 2000 © American LegalNet, Inc. COMMONWEALTH OF VIRGINIA 2f. Page 2 of 7 List below the names and residences of officers, directors, partners, or the sole proprietor: Name Address: THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE VIRGINIA WORKERS' COMPENSATION ACT. VWC Form No. 20 (rev. 11/1/91) 3. Description of operations: 3a. Describe briefly the general character of the operations performed and the articles manufactured or compounded at or away from the plant or premises of the applicant: 3b. Indicate the Standard Industrial Code Number for this business: __________ 3c. List below the Virginia locations, including a brief description of the nature of operations, and the number of employees: 2000 © American LegalNet, Inc. COMMONWEALTH OF VIRGINIA Location Page 3 of 7 Type of operations Number of employees 3d. List below the Virginia payroll, broken down by NCCI payroll classification codes: NCCI code Estimated annual payroll 4. Summary of financial situation for the past three years: 2000 © American LegalNet, Inc. COMMONWEALTH OF VIRGINIA Page 4 of 7 19_____ 19_____ 19_____ Total assets Total liabilities Net worth A complete set of audited financial statements for the last three years must accompany this application. 5. Safety conditions: 5a. Is your plant inspected otherwise than by State authority? If so, by whom? 5b. Yes _______ No _______ ______________________________________________________________ Have you fulfilled all safety requirements of the State Department of Labor and Industry? Yes _______ No _______ 5c. Do you have a safety committee whose duty it is to recommend safety devices and to secure compliance with statutes or general orders of the Department of Labor and Industry as to safety and sanitation? Yes _______ No _______ 6. Summary of claims experience for the last three years: 19_____ 19_____ 19_____ Total number of injuries Number of injuries with 7 or more days lost time Number of dismemberments Number of fatal cases Total compensation paid Total medical paid Total compensation incurred Total medical incurred A detailed report reflecting your claims history for the last three years must accompany this application. 7. Insurance information: 7a. Date self-insurance is to become effective (must be at least 90 days after application is filed): __________ 2000 © American LegalNet, Inc. COMMONWEALTH OF VIRGINIA Page 5 of 7 7b. Indicate the limits of planned excess insurance coverage: Specific retention Specific limit ___________ ___________ Aggregate retention Aggregate limit __________ __________ 7c. Indicate below any other states in which you are operating as a self-insurer for workers' compensation: 7d. Provide the following information regarding your current workers' compensation insurance coverage: Insurance carrier: _______________________________________________________________ Policy number: _______________________________________________________________ Policy period: _______________________________________________________________ 7e. List below other insurance that you carry (type and amount): 8. Claims administration: 8a. Proposed claims administrator (use additional sheets if there are multiple locations): _________________________________________________________ (Individual) _________________________________________________________ (Name of Company) _________________________________________________________ (Mailing Address) _________________________________________________________ (City, State, Zip) _________________________________________________________ (Telephone Number) _________________________________________________________ 8b. In-state designated representative: 2000 © American LegalNet, Inc. COMMONWEALTH OF VIRGINIA Page 6 of 7 _________________________________________________________ (Individual) _________________________________________________________ (Name of Company) _________________________________________________________ (Mailing Address) _________________________________________________________ (City, State, Zip) _________________________________________________________ (Telephone Number) _________________________________________________________ 9. In consideration of the approval of this application, the applicant hereby expressly agrees to the following: 9a. The applicant will pay all benefits required by the Virginia Workers' Compensation Act. 9b. If the Virginia Workers' Compensation Commission so requires, the applicant will deposit with the said Commission acceptable security, indemnity or bond to secure payment of compensation liabilities as they are incurred. Additional security, indemnity or bond may be required in the future. 9c. If the applicant is a subsidiary company or a partnership, the applicant will, if required by the Commission, provide certification that the parent company (or a partner or partners) guarantees that the applicant will fully and promptly pay all sums which are or may become payable under the provisions of the Virginia Workers' Compensation Act and under the terms of the agreement contained in this application. 9d. This privilege may be revoked at any time in the discretion of the Virginia Workers' Compensation Commission, as provided in Section 65.2-808 of the Act. _____________________________________ Signature of Applicant _____________________________________ Official Title City/County of ________________________: 2000 © American LegalNet, Inc. COMMONWEALTH OF VIRGINIA Page 7 of 7 __________________________________________, being first duly sworn, appeared personally and declared that the facts set forth in the foregoing application are true to the best of his or her knowledge, information and belief. Subscribed and sworn to before me, this _______ day of ________________________________, 19_____. (Seal) (Seal) __________________________________________ Notary Public My commission expires on the ______ day of _______________________, 19_______. 2000 © American LegalNet, Inc.