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Application To Self-Insure Workers' Compensation Liabilities - South Dakota Department Of Labor And Regulation Page 3

2. COMPANY BACKGROUND

(2.1) Date Established.

(2.2) If incorporated, under laws of what state?

(2.3) Did firm succeed another firm?

Yes

(2.4) If yes, state whom and date of transition.

(2.5) Name(s) and addresse(es) of parent, subsidiary, and affiliate companies if any. Please specify affiliation.

(2.6) Is the parent, subsidiary or affiliated company guaranteeing the workers' compensation of the applicant?

Yes

*If yes, attach notarized Assumption of Self-Insurance Obligations form.

*If yes, the financial data below should relate to all entities to be self-insured and the guarantor.

*If no, the financial data below should relate only to the entities to be self-insured.

(2.7) List all subsidiaries and affiliates to be self-insured and state the self-insurance retention limit on each. If necessary,

additional subsidiaries and affiliates may be added on "Additional Notes" tab.

(2.8) List name and address, including ZIP + 4, of all administrative branch offices and/or locations in South Dakota (if necessary,

use Additional Notes tab). If applicable, specify which are subsidiaries and which are divisions of the applicant.

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Application To Self-Insure Workers' Compensation Liabilities - South Dakota Department Of Labor And Regulation Page 3