Form Sr-2 - Application To Determine Liability - State Of Alabama (Page 2 of 2) in pdf

Form Sr-2 - Application To Determine Liability - State Of Alabama Page 2

ITEM 9 MUST BE COMPLETED IN ITS ENTIRETY. Use the enclosed instruction sheet for Item 9 to complete Columns 1-5, refer questions

to LMI at 334-242-8873. Please Be Specific. List each location and type of operation or activity separately. (Attach additional sheets if necessary.)

Column

Name and location – Each unit in Alabama. Enter

Alabama

Employee

Indicate specific type of activity in detail

Enter

“Statewide” if no permanent Location

County

Count Per Unit

See Instructions Sheet For Assistance

Percentage

YES ~

NO ~

9a.

Is the above work site primarily engaged in performing support or services for other work sites of the company?

To whom are most of your products sold? GENERAL PUBLIC ~ CONSTRUCTION CONTRACTORS ~

9b.

RETAILERS

WHOLESALERS ~ OTHERS ~ (Specify):______________________________________________________________________

INDIVIDUAL ~

CORPORATION ~

PARTNERSHIP

ASSOCIATION

10. Form of Organization:

ESTATE OR TRUST

LLC

NON-PROFIT ORGANIZATION

OR OTHER

(see 10a.)

(see 10b.)

(Specify):_____________________________________________________________________________

10a. Indicate tax filing status with IRS (include all members and their social security numbers or Federal identification numbers in Item 11):

CORPORATION ~

PARTNERSHIP ~

SOLE PROPRIETOR ~

DISREGARDED ENTITY ~

YES ~ NO ~

10b. Is the organization exempt under 501 (c)(3) of the IRS Code?

(If yes, submit a copy of the 501(c)(3) letter of exemption.)

11. For positive identification, list below the full name(s), social security number(s), and title(s) of individual owner, partners or officers.

Name

Social Security Number

Title

YES ~

NO ~

12. If not otherwise subject, do you wish to voluntarily elect coverage under the Alabama Law?

13.

Name and business location/physical address:

13a.

Tax Preparer/CPA/Accountant:

Name of Applicant, Employer, Corporation, Partnership, Trust, etc.

Tax Preparer/CPA/Accountant

Name of

Trade Name or Division (if different from above)

Physical Address

Address

City

County

State

Zip

City

County

State

Zip

Area Code - Telephone

Area Code - Facsimile

Area Code - Telephone

Area Code - Facsimile

Contact Person

Email Address

Contact Person

Email Address

I certify the information provided on this application is true and correct to be best of my knowledge.

14. Business Name:_______________________________________

Signature:________________________________Date:_________________

NOTE: IF CPA, TAX PREPARER, ETC., IS ONLY SIGNATURE, PLEASE ENCLOSE POWER OF ATTORNEY.

FORM SR2 (Rev. 07/03) CAT NO 53270

PAGE 2 OF 2

Form Sr-2 - Application To Determine Liability - State Of Alabama Page 2

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