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_________________________________________________________________________________________________
(Trust Fund Name)
______________________________________________________________________________________________
(Name) (Title)
______________________________________________________________________________________________
(Name) (Title)
______________________________________________________________________________________________
(Name) (Title)
______________________________________________________________________________________________
(Name) (Title)
We hereby formally apply for continuing membership for workers compensation self-insurance coverage in the above-
named Trust, to be effective 12:01 A.M. ______________________, ____________, and, if accepted by its duly author-
ized representative, do hereby constitute and appoint (if applicable, Service Company) ____________________________
_______________________________________________________________ to act as Administrators of the Trust and as
our agents-in-fact in all matters relating to the Workers Compensation Law.
________________________________________________ _____________________________________________
(Typed Name of Applicant) (Title) (Owner, Partner, Corporate Officer)
________________________________________________ WITNESSES:
(Signature of Applicant)
(1) ________________________________________
(Typed Name)
________________________________________
(Signature)
________________________________________
(Address)
(2) ________________________________________
(Typed Name)
________________________________________
(Signature)
________________________________________
(Address)
________________________________________________
(Corporate President)
________________________________________________
(Date)
By: __________________________________________
(Fund Administrator or Trustee)
WC-81B-2 AI
_________________________________________________________________________________________________
Name of Trust Fund
Experience
From To Gross Payroll Total Losses
___________ ____________ _________________________ ________________
___________ ____________ _________________________ ________________
___________ ____________ _________________________ ________________
___________ ____________ _________________________ ________________
___________ ____________ _________________________ ________________
WC-81B-3 AI