If both the self-insurer and the claims office are located outside the State of Georgia, please designate a GEORGIA AGENT located in the State of Georgia who shall be authorized to execute instruments for the payment of compensation.

Additionally for those claims excluded, please identify, by name, those claims excluded and attach confirmation from SITF or Excess of 100% acceptance of the claim.

Additionally for those claims excluded, please identify, by name, those claims excluded and attach confirmation from SITF or Excess of 100% acceptance of the claim.

Please submit a loss run of all OPEN claims as of 12/31/2011. All other requirements remain the same.

Please attach a written explanation of any variance of 20% (only if the variance is equal to $20,000 or more) or more in the total medical, indemnity, and/or reserve data that you reported on last year’s Update Form, when compared to what you are reporting on this year’s Update Form.

Please note, the captive endorsement and the bankruptcy/cancellation endorsement for excess are two separate endorsements.

Captive insurance endorsement. Added language per the terms of our insurance policy issued to the employer.

Please note, this item is a two part question with part a and b.

a. Please advise when your most recent fiscal year will be completed.

b. If your most recent audited financial statements are not available, please state the date of their availability.