ࡱ> uwt@ ZSbjbj vuu npppp,,,|DDD8||47d( a!t!<w6y6y6y6y6y6y6$8R:r6Q,( ((6pp#6,,,(p,w6,(w6,,616,2 PuyD)2470472@\;)\;82@$dpppp\;,2"#0,$%9"""66||$+|| STATE OF SOUTH CAROLINA DEPARTMENT OF CONSUMER AFFAIRS PROFESSIONAL EMPLOYER ORGANIZATIONS S.C. Code Ann. 40-68-10 et seq.  HYPERLINK "http://www.state.sc.us/consumer" www.scconsumer.gov (803) 734-4200 WORKERS COMPENSATION AFFIDAVIT OF INSURANCE (To be completed by Workers Compensation Insurance Carrier) (Please type or print in black ink) Name of Affiant: FORMTEXT       Name of WC Insurance Carrier: FORMTEXT      Business Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Telephone No: FORMTEXT      Fax No.: FORMTEXT      E-Mail Address: FORMTEXT      Web Site: FORMTEXT       Affiant s Position with WC Insurance Carrier: FORMTEXT       Name of Professional Employer Organization:  FORMTEXT      WC Insurance Policy Number:  FORMTEXT       After being duly sworn upon my oath, I depose and declare that: 1. I am employed by the insurance carrier in the position listed above, and I possess the authority to make the following statements on behalf of that insurance carrier and to bind that insurance carrier concerning the statements made herein. 2. It is my understanding that, as a requirement for licensure as a Professional Employer Organization (PEO) in South Carolina, a PEO may not sponsor a plan for workers compensation insurance which is partially insured or self-insured, or a plan that is not licensed by the South Carolina Department of Insurance. 3. The above listed Workers Compensation Insurance policy is a fully-insured insurance product, and the above-listed insurance carrier is licensed to provide this policy by the South Carolina Department of Insurance. Further, the above listed insurance carrier acknowledges that it is ultimately fully responsible for all incurred claims under the terms of this policy. Affidavit I swear or affirm and certify that I have completed and/or reviewed all information submitted on this form, and to the best of my knowledge and belief, all information contained herein is true, correct and complete; and that there are no material omissions of fact which would have a bearing upon the South Carolina Department of Consumer Affairs decision to grant the requested license. I further certify that I understand that giving false information constitutes cause for denial or revocation of the application and subjects me to criminal prosecution for perjury. I acknowledge that I have a duty and agree to update and correct this information as it changes.  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An original, signed and notarized form is required. The South Carolina Freedom of Information Act may require the Department of Consumer Affairs to release this form as a public record; however personal identifying information will be released only if required by law. Workers Compensation Insurance Affidavit SCDCA Form PEO-09 Revised 08/05 Page  PAGE 1 of  NUMPAGES 2 Street Address 3600 Forest Drive Columbia, SC 29204-4006 Mailing Address P.O. Box 5757 Columbia, SC 29250-5246 Street Address 3600 Forest Drive Columbia, SC 29204-4006 Mailing Address P.O. 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