ࡱ> UWT@ (-bjbj Huu \\\\ZZZ8D4'd:P(xxx5*_{'''''''$")Rt+r?'9\F5FF?'xx#x'FXx\x'F'6#&6\$x  _Z|$&t'0'$@++8$p+\$5-?'?'D  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 INSURANCE CERTIFICATION (Please type or print in black ink) I, FORMTEXT      president and owner of FORMTEXT      a Professional Employer Organization (PEO), as defined in South Carolina Code 40-68-10, et. seq., which is preparing to do business in the State of South Carolina, hereby certify that the above named PEO will not offer any self or partially self-funded plans of insurance for workers compensation, health, life or disability to any employee in the State of South Carolina. I understand that ERISA plans are not acceptable as fully insured health/medical plans for PEOs in South Carolina, and that no insurance plan may be offered to client companies and leased employees without prior approval from this Department. I swear or affirm and certify that I have completed and/or reviewed all information on this form and submitted with this Application, 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. SignatureDate SWORN TO AND SUBSCRIBED before me this ________ day of _____________________, 20______ ________________________________________________ (SEAL) Notary Public For __________________________________ My Commission Expires: _____________________________ Do not fax this form. An original, signed and notarized form is required.  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Box 5757 Columbia, SC 29250-5246 Street Address 3600 Forest Drive Columbia, SC 29204-4006 Mailing Address P.O. 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