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APPLICATION TO FLORIDA MUNICIPAL SELF -INSURER'S FUND NOTIFICATION TO DEPARTMENT OF COMMERCE NAME: ADDRESS: NATURE OF BUSINESS: LIST OFFICIALS OR CORPORATE OFFICERS: I: Name: Title: O Corporation III. Name: Title: H. Name: IV. Name: Title: Title: ❑ Other INSURANCE COVERAGE IS NOW CARRIED BY: I (we) hereby formally apply for continuing membership for Workmen's Compensation Self -Insurance coverage in the above- named fund, to be effective 12:01 a.m., ,19 , and, if accepted by its duly authorized representative, do hereby constitute and appoint the Florida League of Cities, Inc., to act as Administrator(s) of the Fund as our agent(s)-in-fact in all Matters relating to the Workmen's Compensation Law and/or Employer's Liability Act. I (we) further agree as follows: (a) To accept and be bound by the provisions of the Florida Workmen's Compensation Act; (b) That, by this reference, the terms and provisions of the Indemnity Agreement and/or Amendments thereto filed or which may hereafter be filed with the Florida Department of Commerce are hereby adopted, approved, ratified and confirmed by us; and further, I (we) agree to assume all of the obligations set forth therein, and in the event I (we) will pay any premium the date the same shall become due, I (we) will pay all cost of the collection thereof, including reasonable attorney's fee and the maximum rate of interest allowed by law on any past due premiums; (c) To abide by the rules and regulations of the Trustees of the Fund and to conform to the terms of the agreements they may enter into with any authorized service company as long as we remain a member of the Fund; (d) That, in the event of any changes in corporate or business structure, or in legal entity, or if any locations are to be added to or deleted from this coverage, I (we) agree to notify Florida Municipal Self -Insurer's Fund immediately; (e) That should I (we) desire to cancel our coverage, I (we) will give written notice at least 30 days prior to cancellation, and that the Fund will give written notice 30 days prior to cancellation should they desire to cancel our coverage; (f) That coverage under this membership shall be for Florida operations only; (g) That the Wage Declaration Schedule (Form No. ) and/or Renewal Certificates, when completed and returned to us by Florida Municipal Self -Insurer's Fund, become a part of this agreement. I WITNESSES TO SIGNATURE: 5, Name of Applicant Name 2. 7. Officials or Corporate Officer Address 9. CORPORATE SEAL 3. 6. City/Town Clerk 4. Date: 8. Name Address . (Signature may be notarized in place of witnesses) ISA MEMBER OFTHE FLORIDA LEAGUE OF CITIES, INC. AND IS HEREBY APPROVED FOR MEMBERSHIP IN THIS FUND, AND COVERAGE ISEFFECTIVETHE DAY OF , 19 . SIGNEDTHIS BY: DAY OF Fund Administrator/Trustee ,19 SEP 191979 BO 53