Application For Membership In A Group (Page 2 of 3) in pdf

Application For Membership In A Group Page 2

NOTICE: THE INFORMATION IN ITEMS 1 - 5 BELOW IS CONFIDENTIAL

Number of employees working for applicant in Arkansas at this time____________________________________________________

Arkansas workers’ compensation and employer’s liability insurance coverage prior to effective date carried by:__________________

___________________________________________________________________________________________________________

What is the expiration date of applicant's current workers’ compensation coverage? _________________________________________

List the class cod es and descriptions used on the applicant's existing o r previous wo rkers' compe nsation policy.

If the applicant is a new entity, skip this step and proceed with number 5. (Attach an additional sheet if more space is needed)

MANUAL

CODE

DESCRIPTION

Please complete the following, based on the preparation of the proposed group policy

NO. OF

MANUAL

RATE PER

ANNUAL

EMPLOYEES

CODE

CLASSIFICATION

PAYROLL

$100

PREMIUM

To tals

Experience Modifier

________________

Experience M odifier Discount

Premium Size Discount ________________%

Premium Size D iscount

Front-End Discount

________________%

Front-End Discount

Total projected premium to

be paid for the policy period

W e hereby formally apply for continuing membership in the above named group, to be effectiv e at 12:01 A .M.

__________________________, 2____ _____ _, and if accepted by the group's duly authorized repre sentative, do hereby designate

and appoint the named manager of the Group as our agent-in-fact in all matters relating to the workers’ compensation laws and/or

emp loyer’s liab ility.

Page 2 of 3

Form SI-12 (Rev. 8/01/2006)

Application For Membership In A Group Page 2