Compilation of Rules and Regulations of the State of Georgia › Department 120 - OFFICE OF COMMISSIONER OF INSURANCE, SAFETY FIRE COMMISSIONER AND INDUSTRIAL LOAN COMMISSIONER › Chapter 120-2 - RULES OF COMMISSIONER OF INSURANCE › Subject 120-2-34 - GROUP SELF-INSURANCE FUNDS › Rule 120-2-34-.24 - Severability

Current through Rules and Regulations filed through June 27, 2024
If any provision of this Regulation or the application
				  thereof to any person or circumstance, is held invalid by a court of competent
				  jurisdiction, the remainder of the Regulation or the applicability of such
				  provision to other persons or circumstances shall not be affected.
EXHIBIT A
OFFICE OF
COMMISSIONER OF INSURANCE
WARREN D. EVANS
COMMISSIONER OF INSURANCE
SAFETY FIRE COMMISSIONER
INDUSTRIAL LOAN COMMISSIONER
COMPTROLLER GENERAL
SEVENTH FLOOR, WEST TOWER
FLOYD BUILDING
2 MARTIN LUTHER KING, JR. DRIVE
ATLANTA, GEORGIA 30334
APPLICATION FOR CERTIFICATE OF AUTHORITY
FOR GROUP SELF-INSURANCE FUND
To the Commissioner of Insurance, State of Georgia:
Application is hereby made for a Certificate of Authority for
				  Group
Self-Insurance Fund.
(If additional space is required to answer any question, use
				  separate sheets of paper number each to correspond to the question being
				  answered.)
(1) Name of Fund
				  _________________________________________________________
(2) Address of principal office of Fund ___________________
_______________________________________________________________________
(3) Location of Fund records
				  _____________________________________________
(4) Desired effective date of Fund
				  _______________________________________
(5) Address of principal office of association or group
				  ___________
_______________________________________________________________________
(6) Telephone number
				  _____________________________________________________
(7) Name of registered agent of Fund
				  _____________________________________
(8) Address of registered agent of Fund
				  __________________________________
(9) List the complete membership of the Fund and their
				  addresses:
Name
Address
(10) How will the administrative obligations of the Fund be
				  met?
				  _______________________________________________________________________
(11) Name and address of the administrator
				  _______________________________
(12) Is any officer or trustee of the Fund an owner, partner,
				  officer, director, shareholder or employee of the administrator or any parent
				  or affiliated company?
				  ______________________________________________________
If so, explain.
				  __________________________________________________________
(13) Name and address of designated depository
				  ___________________________
(14) Fund balance in depository as of application date
				  ___________________
(15) Other assets of Fund (describe)
				  _____________________________________
(16) Estimated amount of first year normal annual premium
				  ________________
(17) Estimated administrative costs, amount and percentage
				  _______________
(18) Estimated first year losses based on members' loss
				  history of last three years
				  ______________________________________________________________
(19) Other liabilities of Fund (describe)
				  ________________________________
(20) Has each applicant for membership been informed that it
				  will be jointly and severally liable for all liabilities of the Fund?
_______ Yes _______ No
THE FOLLOWING MUST ACCOMPANY THE APPLICATION:
___________ A copy of the bylaws of the Fund
___________ A copy of the intrastate agreement among the
				  members
___________ A copy of any agreement between the Fund and any
				  contract administrator of the Fund
___________ A copy of any contract, endorsement or
				  application form the
Fund intends to use
___________ An "Application for Membership in Group
				  Self-Insurance
Fund" from each member of the Fund
___________ An "Application to Serve as Officer, Director or
				  Trustee of Group Self-Insurance Fund" from any officer, director or member of
				  the board of trustees of the Fund
___________ An "Application to Serve as Administrator of
				  Group
Self-Insurance Fund" from any administrator of the
				  Fund
In consideration of the approval of the application, the
				  applicant agrees to the following:
(A) That its trustees, officers, administrator and members
				  will comply with all provisions of O.C.G.A. Chapter 34-9, the Regulations
				  promulgated thereunder, all lawful Orders of the Commissioner and the Rules and
				  Order of the State Board of Workers' Compensation.
(B) That it will admit as a new member any eligible applicant
				  who complies with the requirements of O.C.G.A. Section
				  34-9-152(h)  and
				  the Regulations thereunder and will notify the Commissioner of its evaluation
				  of each new applicant for membership.
(C) That it will notify the Commissioner of the amount and
				  method of determination of any proposed premium or other assessment to be paid
				  by a member or members.
(D) That it will notify the Commissioner of any dividend in
				  accordance with Regulation.
(E) That any and all books and records of the Fund will be
				  made available for inspection and examination by the Commissioner or his
				  representative.
(F) That the Fund will deposit acceptable securities with the
				  Commissioner in the amount equal to twenty-five percent (25%) of the normal
				  annual premium (ten percent (10%) if the Fund consists of a group of
				  municipalities, counties or school boards) or post surety bond in the form
				  prescribed by the Commissioner in the amount equal to thirty-five percent (35%)
				  of the normal annual premium (fifteen percent (15%) if the Fund consists of a
				  group of municipalities, counties or school boards).
(G) That it will obtain specific and aggregate excess
				  insurance policies written by companies authorized or approved to transact
				  insurance in this State in the amounts prescribed by Regulation or such other
				  amounts as the Commissioner deems necessary, and that it will submit copies of
				  these policies to the Commissioner.
(H) That it will continuously maintain these policies and
				  will, if it desires to make any change in these policies, notify the
				  Commissioner at least sixty (60) days before the proposed effective date of the
				  change.
(I) That the Commissioner may, at any time, revoke, suspend
				  or fail to renew this Certificate of Authority in accordance with O.C.G.A.
				  Section 34-9-169.
(J) THAT THE FUND WILL NOT GUARANTEE ANY FINANCIAL OBLIGATION
				  OF ANY of its OFFICERS, TRUSTEES OR ADMINISTRATORS. ________ (Initial)
(K) THAT NO OFFICER, TRUSTEE, ADMINISTRATOR, OR MEMBER OF ANY
				  COMMITTEE OR EMPLOYEE OF THE FUND WHO IS CHARGED WITH THE DUTY OF INVESTING OR
				  HANDLING THE FUND'S ASSETS WILL BORROW ANY ASSET OF THE FUND; DEPOSIT OR INVEST
				  SUCH ASSETS EXCEPT IN THE NAME OF THE FUND; BE PECUNIARILY INTERESTED IN ANY
				  LOAN, PLEDGE OF DEPOSIT, SECURITY, INVESTMENT, SALE, PURCHASE, EXCHANGE,
				  REINSURANCE OR OTHER SIMILAR TRANSACTION OR PROPERTY OF THE FUND; OR TAKE OR
				  RECEIVE FOR HIS OWN USE ANY FEE, BROKERAGE, COMMISSION, GIFT OR OTHER
				  CONSIDERATION FOR OR ON ACCOUNT OF ANY SUCH TRANSACTION MADE BY OR ON BEHALF OF
				  THE FUND, EXCEPT AS PROVIDED BY O.C.G.A. SECTION
				  34-9-180(c)  OR BY
				  REGULATION OF THE COMMISSIONER ______ (Initial)
(L) That it will notify the Commissioner within fourteen (14)
				  days of any change in any of the information contained in this application.
_______________________________________________________________________
(PRINT NAME OF FUND)
BY:____________________
_______________________
(PRINT NAME)
_______________________
(PRINT TITLE)
_______________________
(DATE)
AFFIDAVIT
COUNTY___________
STATE ___________
I,__________________________________________________________,
				  the undersigned being the _____________________________________________ of
				  the
(Title)
__________________________________________________________________________
(Name of Fund)
swear (or affirm) that to the best of my knowledge and
				  belief, the statements contained in the application, including the accompanying
				  documents, are true and complete.
By:_____________________
Sworn before me this________________
day of______________________, 19 ___
____________________________________
NOTARY PUBLIC
My Commission Expires_______________
EXHIBIT B
OFFICE OF
COMMISSIONER OF INSURANCE
WARREN D. EVANS
COMMISSIONER OF INSURANCE
SAFETY FIRE COMMISSIONER
INDUSTRIAL LOAN COMMISSIONER
COMPTROLLER GENERAL
SEVENTH FLOOR WEST TOWER
FLOYD BUILDING
2 MARTIN LUTHER RING, JR. DRIVE
ATLANTA, GEORGIA 30334
APPLICATION FOR
RENEWAL OF CERTIFICATE OF AUTHORITY
FOR GROUP SELF-INSURANCE FUND
To the Commissioner of Insurance, State of Georgia:
_______________________________________________________________________
(NAME OF FUND)
_______________________________________________________________________
(ADDRESS)
hereby applies for the renewal of its Certificate of
				  Authority for the year
____________. In consideration for the approval of this
				  application, the applicant agrees to all conditions contained in the
				  original
"Application for Certificate of Authority for Group
				  Self-Insurance
Fund." List any changes in the information contained in the
				  Application for Certificate of Authority, as amended by subsequent applications
				  for renewal. Use separate sheets of paper, numbering each to correspond to the
				  question. List changes even if the Commissioner has been notified unless such
				  changes were listed on the previous application for renewal.
_______________________________________________________________________
(PRINT NAME OF FUND)
BY: _________________
_____________________
(PRINT NAME)
_____________________
(PRINT TITLE)
_____________________
(DATE)
AFFIDAVIT
COUNTY_____________
STATE _____________
I,_______________________________________________________,
				  the undersigned being
				  the__________________________________________________________ of the
(Title)
_______________________________________________________________________
(Name of Fund)
swear (or affirm) that to the best of my knowledge and
				  belief; the statements contained in the application, including the accompanying
				  documents, are true and complete.
By:____________________
Sworn before me this__________________
day of______________________, 19______
______________________________________
NOTARY PUBLIC
My Commission Expires_________________
EXHIBIT C
OFFICE OF
COMMISSIONER OF INSURANCE
WARREN D. EVANS
COMMISSIONER OF INSURANCE
SAFETY FIRE COMMISSIONER
INDUSTRIAL LOAN COMMISSIONER
COMPTROLLER GENERAL
SEVENTH FLOOR WEST TOWER
FLOYD BUILDING
2 MARTIN LUTHER RING, JR. DRIVE
ATLANTA, GEORGIA 30334
APPLICATION FOR MEMBERSHIP IN
GROUP SELF-INSURANCE FUND
All information pertaining to the application shall not be
				  deemed to be a public document and shall be maintained in confidence by the
				  Commissioner and the Fund.
To the Commissioner of Insurance of the State of Georgia and
				  the
___________________________________________________________Fund.
Application is hereby made for membership in above
				  Fund.
(1) Member Name
				  ___________________________________________
(2) Address
				  _______________________________________________
(3) Telephone Number ______________ Number of
				  Employees____
(4) Federal Employer I.D. Number
				  __________________________
(5) Nature of Business
				  ____________________________________
(6) Type of Business: () Corporate () Partnership ()
				  Individual
() Other
(7) List of Partners, Owners or Corporate Officers:
NAME
ADDRESS
TITLE
PERCENTAGE OWNERSHIP
(7a) List Chief Administrative Officer of a governmental or
				  hospital entity:
_______________________________________________________________________
(8) If Corporation, name and address of Resident
				  Agent____________________
_______________________________________________________________________
(9) Locations of all operations to be included in the Fund:
NAME
PRINCIPAL
				  ADDRESS
TYPE OF BUSINESS
(10) If applicant is a subsidiary, name parent company:
NAME
ADDRESS
TYPE OF
				  BUSINESS
IF THE APPLICANT IS UNABLE TO OBTAIN ALL THE INFORMATION
				  REQUESTED IN QUESTION (11) IT MAY, INSTEAD, INCLUDE A CERTIFICATION SIGNED BY
				  THE ADMINISTRATOR OR CHAIRMAN OF THE BOARD OF TRUSTEES OF THE FUND THAT the
				  information ACTUALLY PROVIDED IS SATISFACTORY TO THE FUND.
(11) Loss history for last three completed years:
Year Ending
Year
				  Ending
Year Ending
a. Number of accidents requiring medical attention
				  only
b. Number of accidents requiring lost time of more than 3
				  days
Year Ending
Year
				  Ending
Year Ending
c. Total paid claims $ $ $
d. Outstanding reserves $ $ $
e. Total incurred losses $ $ $
(Paid and Reserves)
f. Fatalities in the last three years: No_____ Yes_____
				  Number_____
If yes,
				  explain.___________________________________________________
___________________________________________________________________
(12) Estimated premium for twelve month period
Beginning: Month________ Day______ Year _______
Classification Classification Estimated Current
				  Estimated
Code Description Annual Rate Annual
Payroll Premium
_____________________________________________________________________
Total Payroll ____________________ Total Premium
				  __________________
(13) Present carrier of workers' compensation insurance or
				  indicate if applicant participated in a workers' compensation self-insurance
				  program:
___________________________________________________________________
(14) Present workers' compensation
				  premium_________________________
(15) Statement of Assets and Liabilities as
				  of_____________________
(Date)
APPLICANT MAY SUBMIT A COPY OF THE MOST RECENT AUDITED
				  FINANCIAL STATEMENT CERTIFIED BY A CERTIFIED PUBLIC ACCOUNTANT, IN LIEU OF
				  COMPLETING QUESTIONS (15) AND (16). QUESTIONS (15) AND (16) DO NOT HAVE TO BE
				  ANSWERED BY MUNICIPALITY, COUNTY AND SCHOOL BOARD APPLICANTS.
DOLLARS ONLY
----------------------------------------------------------------------
Current Assets:
Current
				  Liabilities:
Cash on hand ___________________ Accounts Payable
				  __________________
Cash in bank ___________________ Notes payable given for
				  merchandise
Notes receivable ___________________________________
(Less than 1 year old) ________ Notes payable negotiated
				  otherwise
(not transferable) ____________
				  ___________________________________
Merchandise_____________________ Other current liabilities
				  and
Other current assets: accruals:
________________________________
				  ___________________________________
________________________________
				  ___________________________________
________________________________
				  ___________________________________
________________________________ TOTAL CURRENT
LIABILITIES _______________________
TOTAL CURRENT ASSETS: __________
Long-Term
				  Debt:
Fixed Assets:
Notes payable
				  _____________________
Machinery and fixtures _________ Bonded Indebtedness
(net of depreciation) _________ Mortgage Indebtedness
Real Estate Other long-term debts
(net of depreciation)__________ TOTAL LONG-TERM DEBT
Investment (describe nature TOTAL LIABILITIES
of same) _______________________
________________________________
Surplus/Owner
				  Equity:
TOTAL FIXED ASSETS _____________ Capital Stock
				  (Common)
Other non-current assets Paid-in excess
(describe)______________________ Retained Earnings
________________________________ Undivided Profits
________________________________ (Partnership only)
________________________________ Other
				  _____________________________
___________________________________
TOTAL SURPLUS/OWNER EQUITY
___________________________________
TOTAL LIABILITIES, SURPLUS/
TOTAL ASSETS ___________________ OWNERS
				  EQUITY______________________
______________________________________________________________________
______________________________________________________________________
Contingent Liability - Notes Receivable of customers
				  discounted or sold and not included in Assets
				  ___________________________________________
______________________________________________________________________
Other Contingent
				  Liabilities__________________________________________
______________________________________________________________________
If a limited partnership, give date of formation and duration
				  ________
______________________________________________________________________
STATEMENT - Is it based on actual
				  inventory?__________________________
If so, date. ________________________
VERIFICATION - Have the books been audited by a certified
				  public accountant? __________ If so, give date of audit. _____________
If applicant is a corporation: Authorized capital
				  stock
(Common) $_________________________ (Preferred)
				  $_____________________
Paid and subscribed as follows:
Cash ________________________________________
				  $_______________________
Patents, Trademarks _________________________
				  $_______________________
Goodwill ____________________________________
				  $_______________________
Property listed among Assets ________________
				  $_______________________
(16) Relate facts, covering the past three years:
Sales Expenses Payroll Profits
Inc. Payroll)
Year
				  19__________________________________________________________________
Year
				  19__________________________________________________________________
Year
				  19__________________________________________________________________
Amount of indebtedness past due ____________________ $
				  _______________
Insurance of merchandise ___________________________ $
				  _______________
Insurance on buildings and plant ___________________ $
				  _______________
(17) Safety, sanitation and welfare conditions:
Is your business or any part thereof inspected otherwise than
				  by State
Authority? ____________ If so, by whom?
				  _________________________________
Have you fulfilled all safety requirements of the State Board
				  of Workers'
Compensation?__________________
Have you a committee of safety whose duty it is to recommend
				  safety devices and to secure compliance with statutes or general orders of
				  the
Board of Workers' Compensation as to safety and
				  sanitation?______________
Do you maintain a hospital in connection with your
				  works?_________________
If so, state description of its equipment and
				  service.____________________
_______________________________________________________________________
_______________________________________________________________________
In consideration for the approval of this application, the
				  applicant agrees as follows:
(A) That the applicant will comply with O.C.G.A. Chapter
				  34-9, the
Regulations promulgated thereunder, all lawful Orders of the
				  Commissioner, the Rules and Orders of the State Board of Workers' Compensation,
				  and the rules, regulations and bylaws of this Fund.
(B) That the applicant will be jointly and severally liable
				  for all obligations of this Fund during the entire period of membership in the
				  Fund.
(C) That the applicant will pay promptly any lawful premiums
				  or assessments due as a member of the Fund.
(D) That the Commissioner will approve or disapprove this
				  application within the time allowed by O.C.G.A. Section
				  34-9-155 following receipt by him
				  of the application and all supporting information requested.
(E) That the applicant will be notified by at least first
				  class mail as to date (12:01 a.m.) coverage begins which is understood to be
				  the effective date of membership in the Fund.
(F) That the applicant will submit an "Application to
				  Withdraw from
Group Self-Insurance Fund" ninety (90) days prior to
				  voluntary withdrawal from the Fund.
(G) That the coverage under this membership shall be for
				  Georgia operations only, including incidental coverage
in other
				  States.
(H) That the application will notify the Fund and the
				  Commissioner within fourteen (14) days of any change in any of the information
				  contained in questions (1) through (10) of this application.
PLEASE SIGN BELOW - INDICATING THAT YOU HAVE READ AND
				  UNDERSTAND THE ABOVE A. - H.
______________________________
(PRINT NAME OF APPLICANT)
BY: __________________________
______________________________
(PRINT NAME)
______________________________
(PRINT TITLE)
______________________________
(DATE)
AFFIDAVIT
COUNTY________________________
STATE ________________________
I,____________________________________________________, the
				  undersigned being the__________________________________________________of
				  the
(Title)
_______________________________________________________________________
(Name of Applicant)
swear (or affirm) that to the best of my knowledge and
				  belief, the statements contained in the application, including the accompanying
				  documents, are true and complete.
BY:______________________
Sworn to and subscribed before me
				  this_______________________________
day of______________________, 19___.
___________________________________
NOTARY PUBLIC
My Commission Expires______________
EXHIBIT D
OFFICE OF
COMMISSIONER OF INSURANCE
WARREN D. EVANS
COMMISSIONER OF INSURANCE
SAFETY FIRE COMMISSIONER
INDUSTRIAL LOAN COMMISSIONER
COMPTROLLER GENERAL
SEVENTH FLOOR WEST TOWER
FLOYD BUILDING
2 MARTIN LUTHER RING, JR. DRIVE
ATLANTA, GEORGIA 30334
APPLICATION FOR TERMINATION OF MEMBERSHIP
IN GROUP SELF-INSURANCE FUND
_______________________________________, a member in good
				  standing of the _________________________________________ Fund, hereby applies
				  to terminate its membership in the Fund effective ______________________, which
				  date will comply with O.C.G.A. Section
				  34-9-156 requiring the member to
				  give ninety (90) days advance written notice to the Fund and to the
				  Commissioner. The applicant understands and agrees that it will remain jointly
				  and severally liable for all obligations of the Fund as of the date of
				  termination. The applicant will continue to comply with its obligations as an
				  employer under O.C.G.A. Chapter 34-9 as follows: "Secure and maintain full
				  insurance against his liability for payment of workmen's compensation to his
				  employees or provide the State Board of Worker's Compensation with satisfactory
				  proof of his financial ability to pay the compensation directly in the amount
				  and manner and when due as provided in O.C.G.A. Chapter 34-9."
__________________________________
(PRINT NAME OF MEMBER)
BY: ______________________________
__________________________________
(PRINT NAME)
__________________________________
(PRINT TITLE)
__________________________________
(DATE)
AFFIDAVIT
COUNTY_____________
STATE _____________
I,______________________________________________________, the
				  undersigned being the _______________________________________________________
				  of the
(Title)
______________________________________________________________________
(Name of Applicant)
swear (or affirm) that to the best of my knowledge and
				  belief; the statements contained in the application, including the accompanying
				  documents, are true and complete.
By:_________________________
Sworn to and subscribed before me
				  this________________________________
day of_____________________, 19_____.
____________________________________
NOTARY PUBLIC
My Commission Expires_______________
EXHIBIT E
OFFICE OF
COMMISSIONER OF INSURANCE
WARREN D. EVANS
COMMISSIONER OF INSURANCE
SAFETY FIRE COMMISSIONER
INDUSTRIAL LOAN COMMISSIONER
COMPTROLLER GENERAL
SEVENTH FLOOR WEST TOWER
FLOYD BUILDING
2 MARTIN LUTHER RING, JR. DRIVE
ATLANTA, GEORGIA 30334
APPLICATION TO SERVE AS
OFFICER, DIRECTOR OR TRUSTEE OF
GROUP SELF-INSURANCE FUND
To the Commissioner of Insurance, State of Georgia, and the
				  _____________________________________________________________ Fund:
Application is hereby made to serve as ______________________
				  of the Fund.
(If additional space is required to answer any question, use
				  separate sheets of paper, numbering each to correspond to the question being
				  answered.)
(1)
				  Name__________________________________________________________________
(2)
				  Address_______________________________________________________________
(3) Telephone Number
				  _____________________________________________________
(4) Name of Fund
				  _________________________________________________________
(5) Address of Fund
				  ______________________________________________________
(6) Position applied
				  for__________________________________________________
(7) Term of Office
				  _______________________________________________________
(8)
				  Duties________________________________________________________________
(9) Date of Birth
				  ________________________________________________________
(10) Social Security Number
				  ______________________________________________
(11) Have you been convicted of any crime other than minor
				  traffic violations within the last ten years? _____________________If so,
				  explain.
______________________________________________________________________
_______________________________________________________________________
(12) Are you an owner, officer, director, shareholder or
				  employee of any administrator or any parent of affiliated company? ___________
				  If so, explain.____________________________________________________________
_______________________________________________________________________
(13) Educational Background. List all institutions of higher
				  learning,
dates attended, areas of study and degrees received. Include
				  any specialized training, courses or seminars.
(14) Experience. List all relevant employment experience.
				  Include at least three professional references. Include any specialized
				  licenses in any state, memberships in professional, technical or honorary
				  societies, publications, honors or awards. If any license has been refused,
				  suspended, cancelled or revoked, explain.
(15) Have you ever been an officer, director, trustee,
				  investment committee member, key employee or major stockholder of any company
				  which became insolvent, received a cease and desist order, was placed in
				  receivership or conservatorship, was charged with any securities regulation or
				  any insurance violation regulation? ___________________ If so, explain.
				  _______________________________________________________________________
_______________________________________________________________________
(16) Have you ever been declared bankrupt?
				  ________________________ If so, explain.
				  _________________________________________________________________
Enclose any proposed contract with the Fund providing for
				  compensation to the applicant, organization, company or firm in which the
				  applicant is interested.
In consideration for the application, the applicant agrees as
				  follows:
(A) That the applicant will comply with all provisions of
				  O.C.G.A. Chapter 34-9, the Regulations promulgated thereunder, all lawful
				  Orders of the Commissioner, the Rules and Orders of the State Board of Workers'
				  Compensation, the bylaws of the Fund and the terms of any contract with the
				  Fund approved by the Commissioner.
(B) THAT THE APPLICANT WILL BE IN A FIDUCIARY RELATIONSHIP
				  WITH RESPECT TO ANY MONIES OF THE FUND RECEIVED, COLLECTED, DISBURSED, OR
				  INVESTED._______ (Initial)
(C) THAT NO FINANCIAL OBLIGATION OF THE APPLICANT WILL BE
				  GUARANTEED BY THE FUND. ______(Initial)
(D) THAT THE APPLICANT AND ANY COMPANY OR FIRM IN WHICH THE
				  APPLICANT IS INTERESTED WILL NOT DEPOSIT OR INVEST THE FUND'S ASSETS EXCEPT IN
				  THE NAME OF THE FUND, BORROW THE ASSETS OF THE FUND; BE PECUNIARILY INTERESTED
				  IN ANY LOAN, PLEDGE OF DEPOSIT, SECURITY, INVESTMENT, SALE, PURCHASE, EXCHANGE,
				  REINSURANCE OR OTHER SIMILAR TRANSACTION OR PROPERTY OF THE FUND; TAKE OR
				  RECEIVE FOR HIS OWN USE ANY FEE, BROKERAGE, COMMISSION, GIFT, OR OTHER
				  CONSIDERATION FOR OR ON ACCOUNT OF ANY SUCH TRANSACTION MADE BY OR ON BEHALF OF
				  THE FUND; EXCEPT IN ACCORDANCE WITH O.C.G.A. SECTION
				  34-9-180 OR FOR REASONABLE
				  COMPENSATION FOR SERVICES PERFORMED OR SALES OR PURCHASES MADE TO OR FOR THE
				  FUND IN ACCORDANCE WITH THE TERMS OF A CONTRACT APPROVED BY THE COMMISSIONER.
				  ________(Initial)
(E) That any contract providing for compensation from the
				  Fund to the applicant or any company or firm in which the applicant is
				  interested must be approved and may be modified by the Commissioner. In the
				  event of modification by the Commissioner, the applicant reserves the right to
				  withdraw this application.
(F) That the applicant will notify the Fund and the
				  Commissioner within fourteen (14) days of any change in any of the information
				  contained in this application.
______________________
(NAME)
AFFIDAVIT
COUNTY___________
STATE _____________
I,____________________________________________________, the
				  undersigned, being the __________________________________________________of
				  the
(Title)
_______________________________________________________________________
(Name of Applicant)
swear (or affirm) that to the best of my knowledge and belief
				  the statements contained in the application, including the accompanying
				  documents, are true and complete.
BY:_______________________
Sworn to and subscribed before me
				  this________________________________
day of______________________, 19____.
____________________________________
NOTARY PUBLIC
My Commission Expires_______________
EXHIBIT F
OFFICE OF
COMMISSIONER OF INSURANCE
WARREN D. EVANS
COMMISSIONER OF INSURANCE
SAFETY FIRE COMMISSIONER
INDUSTRIAL LOAN COMMISSIONER
COMPTROLLER GENERAL
SEVENTH FLOOR WEST TOWER
FLOYD BUILDING
2 MARTIN LUTHER RING, JR. DRIVE
ATLANTA, GEORGIA 30334
APPLICATION TO SERVE AS
ADMINISTRATOR OF
GROUP SELF-INSURANCE FUND
To the Commissioner of Insurance, State of Georgia, and the
				  __________
__________________________________________________________________
				  Fund:
Application is hereby made to administer the Fund.
(If additional space is required to answer any question, use
				  separate sheets of paper, number each to correspond to the question being
				  answered.)
(1)
				  Name__________________________________________________________________
(2)
				  Address_______________________________________________________________
(3) Telephone
				  Number______________________________________________________
(4) Name of Fund
				  _________________________________________________________
(5) Address of Fund
				  ______________________________________________________
(6) Status: () Corporation () Partnership ()
				  Individual
(7) List Names and Addresses of Owners and Partners
				  ______________________
_______________________________________________________________________
(8) If Administrator is a company, list name and address of
				  Resident Agent
_______________________________________________________________________
(9) List the names, addresses, and titles of the officers and
				  directors of the administrator:
Name
Address
Title
(10) Have any of the above-named people been convicted of any
				  crime other than minor traffic violations within the last ten years?
				  _____________ If so, explain.
				  _____________________________________________________________
(11) Is any officer or trustee of the Fund an owner, partner,
				  officer,
director, stockholder or employee of the administrator or any
				  parent or affiliate company? ______________ If so, explain.
				  _______________________________________________________________________
_______________________________________________________________________
(12) Are you affiliated with or a subsidiary of a company
				  licensed to transact insurance in this State? __________ If so, list names and
				  address.
______________________________________________________________________________________________________________________________________________
(13) List all administrative services you intend to
				  perform.
(14) List those individuals primarily responsible for
				  administering the
Fund and give their experience and educational background
				  including any license in this or any other state within the last ten years. If
				  any license has ever been refused, suspended, cancelled or revoked, explain.
				  Include all institutions of higher learning, dates attended and degrees
				  received, any specialized training courses or seminars, membership in
				  professional, technical or honorary societies, publications, honors or awards.
				  List at least three different professional references for each
				  individual.
(15) Detail the organizational structure and staff, available
				  facilities, equipment and support personnel, how the various administrative
				  services will be performed, and indicate the location in the structure of each
				  individual in question (14).
Enclose a copy of your most recent audited statement of your
				  financial condition (or the most recent annual statement if an insurance
				  company) and of any agreement or contract between you and the Fund.
In consideration for this application, the applicant agrees
				  as follows:
(A) That the applicant will comply with O.C.G.A. Chapter
				  34-9, the
Regulations promulgated thereunder, all lawful Orders of the
				  Commissioner, the Rules and Orders of the State Board of Workers' Compensation,
				  the rules, regulations and bylaws of the Fund and the terms of any contract
				  with the Fund approved by the Commissioner.
(B) THAT THE APPLICANT AND ITS EMPLOYEES WILL BE IN A
				  FIDUCIARY RELATIONSHIP WITH RESPECT TO ANY MONIES OF THE FUND RECEIVED,
				  COLLECTED, DISBURSED OR INVESTED. _______ (Initial)
(C) THAT THE FUND WILL NOT GUARANTEE ANY FINANCIAL OBLIGATION
				  OF the applicant OR ANY OF ITS EMPLOYEES._______(Initial)
(D) THAT THE APPLICANT, ITS EMPLOYEES, AND ANY COMPANY OR
				  FIRM IN which the APPLICANT IS INTERESTED WILL NOT DEPOSIT OR INVEST THE FUND'S
				  ASSETS EXCEPT IN THE NAME OF THE FUND; BORROW THE ASSETS OF THE FUND; BE
				  PECUNIARILY INTERESTED IN ANY LOAN, PLEDGE OF DEPOSIT, SECURITY, INVESTMENT,
				  SALE, PURCHASE, EXCHANGE, REINSURANCE OR OTHER SIMILAR TRANSACTION OR PROPERTY
				  OF THE FUND; TAKE OR RECEIVE FOR HIS OR THEIR OWN USE ANY FEE, BROKERAGE,
				  COMMISSION, GIFT, OR OTHER CONSIDERATION OF THE FUND; EXCEPT IN ACCORDANCE WITH
				  O.C.G.A. SECTION
				  34-9-180, OR FOR REASONABLE
				  COMPENSATION FOR SERVICES PERFORMED OR SALES OR PURCHASES MADE TO OR FOR THE
				  FUND IN ACCORDANCE WITH THE TERMS OF A CONTRACT APPROVED BY THE COMMISSIONER.
				  ________ (Initial)
(E) That any contract providing for compensation from the
				  Fund to the applicant or any company or firm in which the applicant is
				  interested must be approved and may be modified by the Commissioner. In the
				  event of modification by the Commissioner, the applicant reserves the right to
				  withdraw this application.
(F) That the applicant will obtain and maintain a fidelity
				  bond in the amount of $100,000 written by a company authorized to transact
				  insurance in this State and will submit a copy of the bond to the
				  Commissioner.
(G) That the applicant will obtain errors and omissions
				  coverage or other appropriate liability insurance written by a company
				  authorized to transact insurance in this State, in the amount of at least
				  $100,000, and that it will submit a copy of this policy to the
				  Commissioner.
(H) That the applicant will continuously maintain this policy
				  throughout the term as administrator and will, if it desires to make any change
				  in this policy, notify the Commissioner at least sixty (60) days before the
				  proposed effective date of the change.
(I) That the applicant notify the Fund and the Commissioner
				  within fourteen (14) days of any change in any of the information contained in
				  this application.
____________________________
(PRINT NAME OF ADMINISTRATOR)
BY: ________________________
____________________________
(PRINT NAME)
____________________________
(PRINT TITLE)
____________________________
(DATE)
EXHIBIT G
OFFICE OF
COMMISSIONER OF INSURANCE
WARREN D. EVANS
COMMISSIONER OF INSURANCE
SAFETY FIRE COMMISSIONER
INDUSTRIAL LOAN COMMISSIONER
COMPTROLLER GENERAL
SEVENTH FLOOR WEST TOWER
FLOYD BUILDING
2 MARTIN LUTHER RING, JR. DRIVE
ATLANTA, GEORGIA 30334
GROUP SELF-INSURANCE BOND
KNOW ALL MEN BY THESE PRESENTS, that
				  ____________________________________
______________________________________________________________________,
a group self-insurance fund as defined in the laws of the
				  State of ______, as Principal, _________________, a corporation duly
				  incorporated under the laws of the State of ___________, as Surety, are held
				  and firmly bound unto the State of Georgia in the full and just sum of
				  ____________________ dollars, current money of the United States, to be paid to
				  the State of Georgia, to the payment we hereby bind ourselves and each of us,
				  our and each of our successors and assigns, jointly and severally, firmly by
				  these presents, sealed with our seals and dated this _______ day of _________
				  A.D., 19____.
WHEREAS, the above bounden __________________________ did on
				  the _______ day of ____________________, A.D., 19 _______, file with the
				  Commissioner of Insurance of Georgia its application for a certificate of
				  authority for group self-insurance fund under O.C.G.A. Section
				  34-9-152.
AND WHEREAS, the Commissioner on the _______ day of _______,
				  A.D.,
19______, granted the application for the certificate of
				  authority upon condition that _____________________ group self-insurance fund
				  enter into bond in the penalty of _________ dollars conditioned among other
				  things that the fund shall abide by and perform the requirements of the
				  aforesaid Act with reference to paying or furnishing compensation, medical or
				  surgical services, etc., and the rules and regulations that are now or may
				  hereafter be adopted by the Commissioner of Insurance and the State Board of
				  Workers' Compensation.
NOW, THEREFORE, the condition of this obligation is such that
				  if the above bounden __________________________ shall well and truly, from time
				  to time, and at all times hereafter, abide by and perform all the requirements
				  of the aforesaid Act and of any amendments thereto, as well as the rules and
				  regulations that now are or hereafter may be adopted by the State board of
				  Workers' Compensation of Georgia, respecting the payment of the Compensation to
				  any covered injured employees or the dependents of killed employees, and the
				  furnishing at its own cost the expenses of medical, surgical and other
				  services, and funeral expenses as provide in the Act, then this obligation
				  shall be void, otherwise to remain in full force and virtue in law.
This Bond may be cancelled at any time by the Surety upon
				  giving sixty (60) days written notice to the Commissioner of Insurance of
				  Georgia, in which event liability of the Surety shall, at the expiration of the
				  said sixty (60) days, cease and determine, except as to such liability of the
				  Principal on account of injury or death to any covered employees, as may have
				  accrued prior to the expiration of the sixty (60) days, it being understood
				  that the Surety shall be liable, within the penal sum mentioned herein, for the
				  default of the Principal in fully discharging any liability on its part
				  accruing during the life of this obligation.
IN WITNESS WHEREOF, the said Principal has caused these
				  presents to be executed by the signature of the Chairman of its Board of
				  Trustees and the said Surety has caused these presents to be executed by the
				  signature of its _____________________________________ and its corporate seal
				  affixed thereto (Agent or Attorney-in-Fact) with attestation where
				  required.
This ____________ day of ____________________, 19
				  ______.
________________________________________
(Principal) (Name of Fund)
BY:_____________________________________
Title:
Chairman, Board of
				  Trustees
______
________________________________________
(Surety)(Name of Company)
BY:_____________________________________
Title: _________________________________
Attest: ________________________________
(If required by Power-of Attorney)
Title: _________________________________
________________________________________
(SURETY'S SEAL) (Licensed Registered Agent)
Attest as to Seal:
BY: _____________________________
Title: __________________________
EXHIBIT H
OFFICE OF
COMMISSIONER OF INSURANCE
WARREN D. EVANS
COMMISSIONER OF INSURANCE
SAFETY FIRE COMMISSIONER
INDUSTRIAL LOAN COMMISSIONER
COMPTROLLER GENERAL
SEVENTH FLOOR WEST TOWER
FLOYD BUILDING
2 MARTIN LUTHER RING, JR. DRIVE
ATLANTA, GEORGIA 30334
ADMINISTRATOR'S FIDELITY BOND FOR
GROUP SELF-INSURANCE
STATE OF GEORGIA
COUNTY OF ___________________
KNOW ALL MEN BY THESE PRESENTS:
That
				  ____________________________________________________________, whose place of
				  business in the City of ________________________, as Principal, and
				  __________________________________, as Surety, a corporation duly authorized to
				  write surety bonds in this State, are held and firmly bound unto Warren D.
				  Evans, Commissioner of Insurance, State of Georgia, and his successors in
				  office in the penal sum of ONE HUNDRED THOUSAND DOLLARS ($100,000.00) lawful
				  money of the United States of America, for the payment of which well and truly
				  to be made, we bind ourselves, and each of our heirs, executors,
				  administrators, successors and assigns jointly, severally and firmly by these
				  presents:
WHEREAS, the above bounden Principal pursuant to the
				  provisions of O.C.G.A. Chapter 34-9, entitled "Group Self-Insurance Funds," is
				  about to apply or has applied to the Commissioner of Insurance of the State of
				  Georgia to act as administrator of the
				  _______________________________________________
_______________________________________________ Fund.
NOW, THEREFORE, the conditions of the above obligation are
				  such that if the said above bounden Principal shall fully and faithfully comply
				  with the requirements of the said Chapter, and the laws of this State, and
				  shall properly account for all monies collected in connection therewith, then
				  this obligation is to be void, otherwise to remain in full force and
				  effect.
This bond shall remain in full force and effect until the
				  surety is released from liability by the Commissioner or until the bond is
				  cancelled by the surety. The bond may not be cancelled or terminated unless
				  sixty (60) days prior written notice is filed with the Commissioner.
IN WITNESS WHERE OF, the said Principal has caused these
				  presents to be executed by lawful signature under seal and the said surety has
				  caused these presents to be executed by the signature of
				  its_______________________________ and its corporate seal to be affixed
(Agent or Attorney-in-Fact)
there to, with attestation where required.
This ________ day of _____________________________,
				  19____.
_________________________________________
(Principal)(Name of person, corporation, partnership,
				  etc.)
By: _____________________________________
(ADMINISTRATOR'S SEAL) Title:
				  __________________________________
Attest: ____________________ Attest:
				  _________________________________
Title: _____________________ Title:
				  __________________________________
(Secretary of Assistant Secretary)
By: _____________________________________
(SURETY'S SEAL) Title:
				  __________________________________
Attest: ____________________ Attest:
				  _________________________________
(If required by Power-of-Attorney)
Title: __________________________________
_________________________________________
(Licensed Registered Agent)
O.C.G.A. Sec.
				  33-2-9.