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Application To Self-Insure Workers' Compensation Liabilities - South Dakota Department Of Labor And Regulation Page 17

Any employer wishing to continue to self-insure its workers' compensation liabilities under the provisions of Title 62 of the

South Dakota Codified Law must annually furnish a statement of his or her financial condition, not later than the fifteenth

(15th) day of July 2016. The certificate of exemption from the insurance requirements of the Workers' Compensation Law

will expire on the last day of August of each year, unless the certificate is sooner revoked or suspended by the South

Dakota Department of Labor and Regulation, and the permit must be renewed annually through filing of an application and

financial statements. It is understood however, that the employer, upon giving the required notice, may waive this exemption

from the insurance.

If any employer wishes to avail itself of the insurance exemption of the Workers' Compensation Law, it must annually file

with the South Dakota Department of Labor and Regulation, proof as to its solvency and ability to pay the compensation,

benefits, and fees provided by the law, and must submit financial statements as required. If the proof submitted is

satisfactory and a sufficient showing is made, the applicant will be granted permission to operate as a self-insured

employer, upon making the required deposit of securities with the Department of Labor and Regulation. If, however, it is

found from the statement and the proof submitted, that it does not have the financial capacity for the payment of such

compensation, benefits and fees, no certificate of exemption will be granted.

(8.1) STATE of

(8.2) COUNTY of

(8.3) I (we) hereby certify that the foregoing together with all statements or papers attached to and made a part hereof are

true to the best of my (our) knowledge and belief, and (we) hereby bind myself (ourselves) and my (our) heirs, executors

and assigns to the complete fulfillment of all agreements here-in contained.

Subscribed and sworn to before me this

day of

, 2016.

My commission expires

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Application To Self-Insure Workers' Compensation Liabilities - South Dakota Department Of Labor And Regulation Page 17