Free Form SI-02 - Kentucky

FORM S I-02 REV. 01/04

DEPARTMENT OF WORKERS' CLAIMS FRANKFORT, KENTUCKY 40601

EMPLOYERS APPLICATION FOR PERMISSION TO CARRY HIS OWN RISK WITHOUT INSURANCE TO THE DEPARTMENT OF WORKERS' CLAIMS OF KENTUCKY: , 20 .

The undersigned, an employer subject to the provisions of The Kentucky Workers' Compensation Act, hereby applies for a certificate of his-its financial ability to pay compensation directly, without insurance to injured employees, and determine whether he-it possesses sufficient financial ability to render certain the payment of such compensation, said applicant under oath hereby states the following facts: (Where space is insufficient to answer any question, extend answer on attached page or pages.) 1. 2. Name of applicant: Address: (Number) (Street) (City or Town)

________________________________________________________________________________ (County) (State) 3. 3.a The applicant is (State whether individual, co-partnership, corporation, receiver or trustee.)

If consolidated balance sheet give list of subsidiary companies included: ______________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Describe briefly the general character of the operations performed and the articles manufactured or compounded at or away from the plant or the premises of the applicant. Description of Employment:

4.

5.

Location of Plant Or Plants

Kind of Employment

Average # of Employees at all points

Average # of Employees in Kentucky

Actual Payroll For all employees In Kentucky

TOTALS:

6. 7.

If a corporation, partnership, or Limited Partnership, list below names of officers, directors, and residence of each. ___________________________________________________________________________________________ Safety, sanitation and welfare conditions: Is your plant inspected otherwise than by State authority? _______________________________________ If so, by whom? _________________________________________________________________________ Have you fulfilled all safety requirements of the Labor or Mines and Mineral Departments? _______________________________________________________________________________________ Have you a committee of safety whose duty is to recommend safety devices and to secure compliance with statutes or general orders of the above-mentioned agencies as to safety and sanitation? _________________________________ Do you maintain a hospital in connection with your establishment? ________________________________ If so, state description of its equipment and service: _____________________________________________

8.

Federal Employer I.D. # State Employer I.D. # ____________________________________ Federal and State I.D. #'s are needed for each subsidiary, if any are to be included.

9.

In consideration of the approval of this application the applicant hereby expressly agrees as follows: a. That this privilege may be revoked at any time in the discretion of The Department of Workers' Claims. b. That the applicant will fully discharge by cash payment all installments of compensation for partial disability, promptly, when due, and liability for physician fees, hospital service, hospital supplies within 30 days after such liability shall be determined either by an agreement or an award. c. If The Department of Workers' Claims so requires, the applicant, within thirty days after his-its continuing liability to pay compensation to an injured employee for a definite period for a permanent injury or to the dependents of a deceased employee, for his death, has been determined either by an agreement or an award, will make a special deposit, with some bank or trust company within the Commonwealth of Kentucky to be approved by the Department of Workers' Claims of the full amount of such terms that it can be withdrawn only on the checks of the applicant, payable to the person or persons entitled thereto, and having attached thereto a voucher for the amount thereof, executed by the person or persons to whom such check is payable. d. The applicant agrees to file with the Department of Workers' Claims for its approval before the granting of this application, an acceptable security, indemnity of bond, to secure to such an extent as the Department of Workers' Claims may direct the payment of compensation liabilities as they are incurred. Requested effective date to become self-insured:

10.

If Corporation By President and Managing Officer COMMONWEALTH OF KENTUCKY COUNTY OF

, being first duly sworn, upon oath, says that the facts set forth in the foregoing application are true.

Subscribed and sworn to before me, this

day of

, 20

.

Notary Public My commission expires on the day of , 20 .