Enrollment Application

The Montana State Fund (MSF) and the Montana Food Distributors Association (MFDA) have entered into an agreement to

provide a group program to qualifying MFDA members. To participate in the program, a group member must complete and

sign this Application.

General Provisions

Acceptance into the group program is subject to approval based on the eligibility criteria for the program. The criteria define

the classes of business that qualify and eligible loss ratio and/or experience modification factors. The effective date of the

policy must be within the contract year. This enrollment application must be received within 90 days of the effective date of

the policy to be considered for participation in the group program.

Participating members shall:

1. Maintain an individual workers’ compensation policy with MSF and be subject to the terms of the policy.

2. Report all accidents immediately to MSF at 1-800-332-6102.

3. Adhere to and comply with the minimum safety requirements of the Montana Safety Culture Act and actively participate in

the loss control program conducted by MFDA. Participation in the loss control program may include but is not limited to

attendance at a safety-related seminar, on site safety audit or response to a correspondence type program including but

not limited to program-specific materials or publications.

4. Maintain MFDA membership in good standing.

5. Agree to a policy date from April 1st to April 1st to be concurrent with the group plan policy year.

MFDA shall:

1. Assist Montana State Fund in implementation of the plan.

MSF shall:

1. Retain exclusive responsibility for underwriting, individual policy issuance and cancellation, claims management and

administration.

2. Develop and implement loss control program.

Release

By signing this form, I authorize MSF to release to MFDA (for internal use only) premium and loss data on my workers’

compensation policy, information which reflects the timeliness of reporting any work related injuries and the status of my

adherence to the terms of the group contract.

Termination

1. MSF may terminate a member’s participation in this program if the insured does not maintain MFDA membership in good

standing, no longer meets the eligibility criteria for participation in the group program or is in default of an obligation to

MSF. MSF may terminate a member’s participation by serving notice in writing. Termination is effective the date specified

in the notice. If no date is specified in the notice, the date of the written notice is the termination date.

2. Members may terminate their participation by serving notice in writing to MSF. Termination is effective the date of the

written notice.

Effective Date

If the enrollment application is received by MSF within 90 days of the effective date of the policy within the contract year and

the policy qualifies, participation shall commence on the effective date of the policy.

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