FORM S I-02
DEPARTMENT OF WORKERS’ CLAIMS
REV. 01/04
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.
Name of applicant:
2.
Address:
(Number)
(Street)
(City or Town)
________________________________________________________________________________
(County)
(State)
3.
The applicant is
(State whether individual, co-partnership, corporation, receiver or trustee.)
3.a
If consolidated balance sheet give list of subsidiary companies included: ______________________________
________________________________________________________________________________________
________________________________________________________________________________________
4.
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.
5.
Description of Employment:
Location of Plant
Kind of
Average # of
Average # of
Actual Payroll
Or Plants
Employment
Employees at all
Employees in
For all employees
points
Kentucky
In Kentucky
TOTALS:
6.
If a corporation, partnership, or Limited Partnership, list below names of officers, directors, and residence of each.
___________________________________________________________________________________________
7.
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.
FORM S I-02
DEPARTMENT OF WORKERS’ CLAIMS
REV. 01/04
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.
Name of applicant:
2.
Address:
(Number)
(Street)
(City or Town)
________________________________________________________________________________
(County)
(State)
3.
The applicant is
(State whether individual, co-partnership, corporation, receiver or trustee.)
3.a
If consolidated balance sheet give list of subsidiary companies included: ______________________________
________________________________________________________________________________________
________________________________________________________________________________________
4.
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.
5.
Description of Employment:
Location of Plant
Kind of
Average # of
Average # of
Actual Payroll
Or Plants
Employment
Employees at all
Employees in
For all employees
points
Kentucky
In Kentucky
TOTALS:
6.
If a corporation, partnership, or Limited Partnership, list below names of officers, directors, and residence of each.
___________________________________________________________________________________________
7.
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.
10.
Requested effective date to become self-insured:
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
.
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