Application For Membership In A Group printable pdf download

Application For Membership In A Group

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

Individual

Corporation

(FEIN):

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.)

Name of officers, owners or partners, and addresses

(First name)

(MI)

(Last name )

(Title)

(Address)

Include for Coverage

Yes

Page 1 of 3

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

Application For Membership In A Group