Application For Membership In A Group

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ARKANSAS WORKERS’ COMPENSATION COMMISSION
Form SI-12
Rev. 8/01/2006
SELF-INSURANCE DIVISION
SI-12
324 Spring Street, Little Rock, AR 72201
Ark. Code Ann.
Mail: P. O. Box 950, Little Rock, AR 72203-0950
§11-9-404 &
501-682-2783 / 1-800-622-4472
AWC C Rule 099.05
APPLICATION FOR MEMBERSHIP IN A GROUP
Name o f Group Self-Insurer:
Name o f App licant:
Telephone N umber (
)
Facsimile Number (
)
Mailing Address:
City, State, and Zip Code:
Years in Business:
Application is for:
Federal Employer Identification Number
G
G
Individual
Corporation
(FEIN):
G
G
Partnership
Other (please specify)
Nature o f Business:
PH YS ICA L LO CATION S: List physical address, city, state, and zip code - (If more locations, please list on a separate page and attach.)
1.
2.
3.
4.
5.
6.
Name of officers, owners or partners, and addresses
(First name)
(MI)
(Last name )
(Title)
(Address)
Include for Coverage
G
G
1.
Yes
No
G
G
2.
Yes
No
G
G
3.
Yes
No
G
G
4.
Yes
No
G
G
5.
Yes
No
Page 1 of 3
Form SI-12 (Rev. 8/01/2006)

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