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

W e further agree as follows:

A. To accept and be bo und by the p rovisions of the Arkansas workers’ comp ensation laws.

B. That, by application and reference, the terms and provisio ns of the Gro up Indem nity Agre ement and/or Amendme nt thereto

filed, or any renewal Indemnity Agreement which may hereafter be filed with the Arkansas Workers’ Compensation

Commission are hereby adop ted, ap proved, ratified and confirmed by us: and, further, we agree to assume all of the

obligations set forth therein, including, but not limited to, our joint and several liabilities for payment of any lawful awards

against any member of the Group.

C. To abide by the rules and regulations of the Trustees of the Group and to conform to the terms of the agreements they may

enter into with any authorized third party administrator as long as we remain a member of the group.

D. W e agree to give at least thirty (30) days written notice to the Group prior to our withdrawal as a member. In the event, of

any changes in ownership, corporate structure, legal entity, nature of business or if any locations are to be added or deleted,

we agree to so notify the Group immediately. The Group will give written notice thirty (30) days prior to cancellation or

expulsion of any member.

_________________________________________________

(Na me o f applicant)

________________________________________________

(Printed N ame of autho rized officer o f App licant)

________________________________________________

(Signa ture of authorized o fficer of Applicant)

________________________________________________

(Title of officer)

State of Arkansas

County of ___________________________

Subscribed and sworn to me by ____________________________________________________________ on this _______________

day of _______________________________, 2__________.

___________________________________________________

No tary Public

My Commission Expires: _____________________________

The application and supporting documents of _________ _________ _________ _________ _________ have been properly received

and noted .

Said applicant is here by approved and accep ted for membership in the Group effective the __________ day of

________________________, 2 ______.

____________________________________________________________________

(Name of Group)

By:

____________________________________________________________________

Chairman, Board of Trustees

____________________________________________________________________

Date of Signing

Page 3 of 3

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

Application For Membership In A Group Page 3