State the company name in which your self-insurance is registered. State the name of the person who is our primary contact person at the member company, along with his/her address and telephone number.

State the name of the person who is our secondary contact, along with his/her address and telephone number.

Revised State Board of Workers’ Compensation contact name, telephone number and e-mail address.

Attach a copy of your third-party administrator’s Georgia TPA license. Please note, such license can be obtained by contacting the Office of Insurance and Safety Fire Commissioner at (404) 656-2056. Added language: If your TPA is exempt from licensure, please provide a copy of the signed exemption letter. For an example of the exemption letter, please visit our website at www.gaguaranty.com.

Was there a change in ownership of your company last year, or did you buy or sell subsidiary companies last year? Moved from question #29 on the active member form.

Submit a loss run, as of 12/31/10, for your company, and a separate loss run for subsidiaries and affiliates, if any.

Submission of the loss run for your company may be made by thumb drive or CD, if preferable.

Please note, once data is submitted, no changes may be made. Please ensure accuracy of data before sending.

Please attach a written explanation of any variance of 20% or more in the total medical, indemnity, and/or reserve data that you reported on last year’s update form. Moved from question #21 on the active member form, and question #27 on the cancelled member form.

Please attach a list of all claims designated to be catastrophic along with their respective reserves. Added language: If none, please indicate N/A here: _____________.

Captive insurance endorsement. Removed language, “per your agreement with this employer”.

Captive endorsement page to be completed by captive insurer, requesting the following information: Endorsement Number, Named Insured, Policy Number, with Authorized Representative signature, and date. Added contact information for Fund and State Board of Workers’ Compensation.

Please advise who is responsible for notifying your excess carrier of claims eligible for reimbursement.

Please advise who is responsible for notifying the SITF of claims eligible for reimbursement.

For submitting audited financial statements, if preferable, list your company’s website address.