SCDCA Form PEO-09 "Workers' Compensation Affidavit of Insurance" - South Carolina

What Is SCDCA Form PEO-09?

This is a legal form that was released by the South Carolina Department of Consumer Affairs - a government authority operating within South Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the South Carolina Department of Consumer Affairs;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of SCDCA Form PEO-09 by clicking the link below or browse more documents and templates provided by the South Carolina Department of Consumer Affairs.

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Download SCDCA Form PEO-09 "Workers' Compensation Affidavit of Insurance" - South Carolina

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S
S
C
TATE OF
OUTH
AROLINA
D
C
A
EPARTMENT OF
ONSUMER
FFAIRS
PROFESSIONAL EMPLOYER ORGANIZATIONS
S.C. Code Ann. § 40-68-10 et seq.
Mailing Address
Street Address
www.consumer.sc.gov
P.O. Box 5757
293 Greystone Blvd., Suite 400
(803) 734-4200
Columbia, SC 29250-5757
Columbia, SC 29210
WORKERS’ COMPENSATION AFFIDAVIT OF INSURANCE
(To be completed by Workers’ Compensation Insurance Carrier)
Name of Affiant:
Name of WC
Insurance Carrier:
Business Address:
City:
State:
Zip:
Telephone No:
Fax No.:
E-Mail Address:
Web Site:
Affiant’s Position with
WC Insurance Carrier:
Name of PEO:
WC Insurance
Policy Number:
FEIN:
After being duly sworn upon my oath, I depose and declare that:
1.
I am employed by the insurance carrier in the position listed above, and I possess the authority to make the
following statements on behalf of that insurance carrier and to bind that insurance carrier concerning the
statements made herein.
2.
It is my understanding that, as a requirement for licensure as a Professional Employer Organization (PEO)
in South Carolina, a PEO may not sponsor a plan for workers’ compensation insurance which is partially
insured or self-insured, or a plan that is not licensed by the South Carolina Department of Insurance.
The above listed Workers’ Compensation Insurance policy is a fully-insured insurance product, and the
3.
above-listed insurance carrier is licensed to provide this policy by the South Carolina Department of
Insurance. Further, the above listed insurance carrier acknowledges that it is ultimately fully responsible
for all incurred claims under the terms of this policy.
Workers’ Compensation Insurance Affidavit
SCDCA Form PEO-09
Revised 07/19
Page 1 of 2
S
S
C
TATE OF
OUTH
AROLINA
D
C
A
EPARTMENT OF
ONSUMER
FFAIRS
PROFESSIONAL EMPLOYER ORGANIZATIONS
S.C. Code Ann. § 40-68-10 et seq.
Mailing Address
Street Address
www.consumer.sc.gov
P.O. Box 5757
293 Greystone Blvd., Suite 400
(803) 734-4200
Columbia, SC 29250-5757
Columbia, SC 29210
WORKERS’ COMPENSATION AFFIDAVIT OF INSURANCE
(To be completed by Workers’ Compensation Insurance Carrier)
Name of Affiant:
Name of WC
Insurance Carrier:
Business Address:
City:
State:
Zip:
Telephone No:
Fax No.:
E-Mail Address:
Web Site:
Affiant’s Position with
WC Insurance Carrier:
Name of PEO:
WC Insurance
Policy Number:
FEIN:
After being duly sworn upon my oath, I depose and declare that:
1.
I am employed by the insurance carrier in the position listed above, and I possess the authority to make the
following statements on behalf of that insurance carrier and to bind that insurance carrier concerning the
statements made herein.
2.
It is my understanding that, as a requirement for licensure as a Professional Employer Organization (PEO)
in South Carolina, a PEO may not sponsor a plan for workers’ compensation insurance which is partially
insured or self-insured, or a plan that is not licensed by the South Carolina Department of Insurance.
The above listed Workers’ Compensation Insurance policy is a fully-insured insurance product, and the
3.
above-listed insurance carrier is licensed to provide this policy by the South Carolina Department of
Insurance. Further, the above listed insurance carrier acknowledges that it is ultimately fully responsible
for all incurred claims under the terms of this policy.
Workers’ Compensation Insurance Affidavit
SCDCA Form PEO-09
Revised 07/19
Page 1 of 2
AFFIDAVIT
I swear or affirm and certify that I have completed and/or reviewed all information submitted on this form, and
to the best of my knowledge and belief, all information contained herein is true, correct and complete; and that
there are no material omissions of fact which would have a bearing upon the South Carolina Department of
Consumer Affairs’ decision to grant the requested license. I further certify that I understand that giving false
information constitutes cause for denial or revocation of the application and subjects me to criminal prosecution
for perjury. I acknowledge that I have a duty and agree to update and correct this information as it changes.
Signature
Date
Type or Print your name and Title
SWORN TO AND SUBSCRIBED before me
this ________ day of _____________________, 20______
________________________________________________
(SEAL)
Notary Public For __________________________________
My Commission Expires:
_____________________________
The completed Application should be submitted to:
South Carolina Department of Consumer Affairs
Attn: PEO Licensing
Mailing Address
Street Address
P.O. Box 5757
293 Greystone Blvd., Suite 400
Columbia, SC 29250-5757
Columbia, SC 29210
Do not fax this form. An original, signed and notarized form is required.
The South Carolina Freedom of Information Act may require the Department of Consumer Affairs to release
this form as a public record; however personal identifying information will be released only if required by law.
Workers’ Compensation Insurance Affidavit
SCDCA Form PEO-09
Revised 07/19
Page 2 of 2
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