164-22 Exhibits to Agreement for Workers Compensation Third Party Administration - 2022.pdf

STOCKHOLDER DISCLOSURE CERTIFICATION, I certify that the list below contains the names and home addresses of all stockholders holding 10% or more of the issued and outstanding stock of the undersigned. I certify that no one stockholder owns 10% or more of the issued and outstanding stock of the undersigned. PLEASE, CHECK TYPE OF BUSINESS ORGANIZATION: Partnership Limited Partnership Limited Liability Corp i Corporation. Sole Proprietorship Limited Liability Partnership __ 7 Subchapter S Corp PLEASE CHECK APPROPRIATE BOXES AND SIGN BELOW ‘Name: Home Address: | | Stockholders ‘Name: Home Address: | Name. Home Address: Name: Home Address: Owner or Representative Signature Print Name & Title NOTORY PUBLIC Sworn before me this day of 20 Ho a pg