Declaration of Applicant For Group Membership

The applicant is a member of the Association of All Great Retailers. The Applicant agrees to promptly pay all Group Workers’ Compensation premium and deposits when billed and due. The applicant understands and agrees that upon failure to pay any outstanding financial obligations due on his account to the insurer, or to maintain Association membership, the Applicant will immediately cease to be a Group Member. The applicant gives the Group Secretary power of attorney to obtain and use, in the interests or the Group of the individual Member, any information held by the insurer relating to claims, experience rating, loss prevention services or other information which may be the subject of Group research and inquiry. The applicant constitutes and appoints the Board of Directors (or the Secretary of the Association if the Directors are not present) as the Member’s proxy to attend all meetings of the Members of the Association, with full power to vote as proxy for the Member and act in the Member’s name and place, in the same manner, to the same extent and with the same effect that the Member might have if personally present.  This grant of a proxy shall continue in force indefinitely unless revoked in writing.  Each Member at any time may decline to grant said proxy or revoke said proxy by written notice to the Secretary