Fill and Sign the New York Compensation 497321709 Form

NOYES NO YES                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             / / GSI-1.1 (11-94)STATE OF NEW YORK WORKERS' COMPENSATION BOARD APPLICATION FOR PARTICIPATION IN GROUP SELF-INSURANCE PLAN Submit this Form to the Workers' Compensation Board, Attention: Self-Insurance office 1 - NAME OF APPLICANT: 2. ADDRESS (Principal Office): 3. TELEPHONE: 4. FEDERAL EMPLOYER IDENTIFICATION NUMBER: 5. NYS U.I. EMPLOYER REGISTRATION NUMBER: 6. EFFECTIVE DATE OF PARTICIPATION: (a) Describe briefly the general character of the operations performed and thearticles manufactured or compounded at the plant or on the premises ofthe employer. if more than one class of work is conducted, indicate division inpayroll of each. (c.) Describe briefly all classes of work performed away from the employees plant Nature of Business or premises, including the demonstration, it any, the employer's product (b) StandardIndustrialClassificationCode (SIC) 8. WHAT COMPANY NOW IS CARRYING YOUR COMPENSATION INSURANCE? THIS COVERAGE MUST NOT BE TERMINATED UNTIL AFTER THE APPROVALOF THIS APPLICATION. Report full payrolls for all employees, include interstate, maritime, homeworkers, value of meals and lodging, etc., received by employees and sub-contractors' employees payrolls unless compensation is definitely provided by sub-contractors. 9. 10. 11. 12. CLASS NO. DIVISIONS OF OPERATIONS ESTIMATED AVERAGE NUMBER ESTIMATED PAYROLL OF ALL (DIVIDE PAYROLL TO CORRESPOND WITH DIVISIONS BELOW) OF EMPLOYEES EMPLOYEES FOR ONE YEAR (a) Employees engaged in general operations upon the employer's premises, operative management and superintendence and ordinary repairs and upkeep of machinery and ordinary repairs tobuildings. (b) Clerical office and others engaged in office duties at the plant or an the promises of the employer. (c) Sales personnel, collectors and messengers outside. (d) Sales personnel within buildings. (e) Chauffeurs, drivers, and their helpers; (motor and/or horse-driven vehicles). (f) Executive Officers, corporate (elected or appointed in accordance with the charter or by-laws). (g) Description of operations not Included In above. TOTALS 13. IF A (a) Enter date when incorporated. (b) Under laws of what State? (c) If not a New York CORPORATION ... corporation , enter dateof registration in NewYork State. (d) Has applicant any affiliates or subsidiaries with operations in New York State? (e) Did you succeed anyone? If yes, whom did you succeed? (f) If a subsidiary, enter name and address of parent company. 14. IF A PARTNERSHIP... (a) Name all partners and designate whether they areGeneral (G), Special (S), Limited (L). Other. Name G S L Specify Other I (g) Enter parent's percentage of stock ownership: PERCENT 15. IF A SOLE PROPRIETORSHIP ... Indicate home address of proprietor. (b) Enter date when partnership was established. CERTIFICATION ON REVERSE SIDE TO BE COMPLETED BY AUTHORIZED OFFICIAL OR GROUP SELF-INSURER. ATTACH TO THIS APPLICATION: 1. A payroll report filed by classification code for the employer for five preceding annual fiscal periods 2. A report indicating compensation and medical losses, both payments and reserves, incurred by the employer for a period up to ten years prior to the date of application .                                                                                         Approved Disapproved .The undersigned hereby affirms, under the penalties of perjury, that (s)he is Title of , the participating employer named above and that the foregoing Company Name statement is true. Participating Employer Printed or Typed Name of Company Official Date Signed Signature CERTIFICATION BY GROUP SELF-INSURER. STATE OF NEW YORK COUNTY OF , being duly sworn, says: Name of Authorized Official That (s)he is the of the an d Title Name of Group Self-insurer Is duly authorized to execute this affidavit of certification on behalf of said Group Self-Insurer. That this EMPLOYER'S participation will continue to be effective until ten days after a written notice of termination is served on the EMPLOYER and filed with the Chair, Workers' Compensation Board, by the Self-insurer. That all employees of this EMPLOYER will be covered under the Workers' Compensation Law by the Group Self-Insurer. Signature of Authorized Official Sworn to before me this day of Signature of Notary Public FOR WORKERS' COMPENSATION BOARD USE ONLY Director of W.C.Regulatory Services Date GSS-1.1 Reverse (11-94)