ASP ENROLLMENT APPLICATION
SCF Arizona FAX 602.631.2609 3030 N 3rd Street Phoenix AZ 85012 3068

Policyholder Information

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Policyholder Name/dba

Street Address

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Company Safety Manager/Director

Safety Contact Phone Number		E-mail Address

Policy Number		with SCF Arizona/SCF Western/SCF General/SCF Premier, hereby applies for enrollment in:

Choose Your Association AGING SERVICES OF ARIZONA AHWATUKEE FOOTHILLS C OF C AIR CONDITIONING CONTRACTORS OF AZ ALLIANCE OF CONSTRUCTION TRADES AMERICAN SUBCONTRACTORS ASSN OF ARIZONA, INC AUTOMOTIVE SERVICE ASSN OF AZ INC AZ AGRICULTURE AVIATION ASSN AZ AUTOMOBILE DEALERS ASSOCIATION AZ BUILDERS ALLIANCE AZ BUSINESS ASSN INC AZ CATTLE GROWERS/FEEDERS ASSN AZ CHAP/ASSOCIATED GEN CONTRS OF AMERICA AZ CONTRACTORS ASSN AZ FARM BUREAU FEDERATION AZ FOOD MARKETING ALLIANCE AZ HOSPITAL & HEALTHCARE ASSN AZ LANDSCAPE CONTRACTORS ASSN AZ LICENSED BEVERAGE ASSN AZ MASONRY CONTACTORS ASSN INC AZ MULTIHOUSING ASSN AZ NURSERY ASSN AZ PEST MANAGEMENT ASSN AZ PETROLEUM MARKETERS ASSN AZ RESTAURANT & HOSPITALITY ASSOCIATION AZ RETAILERS ASSN AZ ROOFING CONTRACTORS ASSN AZ SCHOOL BOARDS ASSN INC AZ SIGN ASSN INC AZ SMALL BUSINESS ASSN AZ SOCIETY OF CPAS AZ TOOLING & MACHINING ASSN AZ WATER WELL ASSN BULLHEAD AREA C OF C CERAMIC TILE & STONE ASSN OF AZ CHANDLER C OF C COLORADO RIVER BLDG INDUSTRY ASSN CONTRACTORS ASSN OF NO AZ COTTONWOOD C OF C FLAGSTAFF C OF C GILBERT C OF C GLENDALE C OF C GREATER CASA GRANDE C OF C GREATER PHOENIX C OF C GREATER SIERRA VISTA AREA C OF C HOME BUILDERS ASSN OF CENTRAL AZ KINGMAN AREA C OF C INDEPENDENT ELECTRICAL CONTRS ASSN LAKE HAVASU AREA C OF C MARANA C OF C NATIONAL FEDERATION OF INDEPENDENT BUSINESS (NFIB) MESA C OF C MOHAVE VALLEY CONTRACTORS ASSN INC NATL UTILITY CONTRACTORS ASSN OF AZ NORTHERN AZ BUILDING ASSN NORTHERN AZ LOGGERS ASSN PDCA CENTRAL ARIZONA CHAPTER NO. 1 PEORIA C OF C PLUMB & A/C CONTRS ASSN - PHX PRESCOTT C OF C PRESCOTT VALLEY C OF C PRINTING INDUSTRIES ASSN INC OF AZ SEDONA C OF C SCOTTSDALE C OF C SOUTHERN AZ HOME BUILDERS ASSN SOUTHWEST VALLEY C OF C SURPRISE REGIONAL CHAMBER OF COMMERCE TEMPE C OF C TUCSON METRO C OF C TUCSON UTILITY CONTRACTORS ASSN VERDE VALLEY CONTRACTORS ASSN WICKENBURG C OF C YAVAPAI COUNTY CONTRACTORS ASSOCIATION YUMA SOUTHWEST CONTRACTORS ASSOCIATION Association Name

Qualification
I am a policyholder with SCF Arizona, SCF General Insurance Company, SCF Premier Insurance Company or SCF Western Insurance Company, hereinafter referred to as SCF.

1) I attest to being a "member in good standing" of the above named association through which I am applying to enroll in its Association Safety Program, hereinafter known as ASP. Member in good standing is defined by the respective Association.

2) By joining an ASP, I authorize the Association to obtain premium and loss information from SCF pertaining to the above-numbered policy and previous SCF policies for this business and its related policies. The Association and SCF shall have the authority to determine eligibility of the member to participate in the ASP based on SCF underwriting guidelines and the applicant's loss history. The Association and its safety committee will review this information to develop safety training, monitor eligibility and implement programs to encourage workplace safety.

Dividends
3) Participating ASP policyholders in SCF Arizona may earn a bonus safety dividend. To be eligible, the policyholder must be an Association "member in good standing," i.e., the Association dues must be paid in full for the period of the earned dividend. The Association may provide the policyholder/member the opportunity to bring dues current.

Note: SCF Arizona and its subsidiaries are separate entities. SCF Arizona historically has declared and paid dividends; the subsidiaries have not. Dividends are never guaranteed; if and when dividends are declared, it is up to the respective Boards of Directors for each individual company.

4) Individual or bonus dividends payable to a participating SCF Arizona policyholder/member, shall be credited against any unpaid premium before being paid to the policyholder.

Participation
5) In the event the policy of a participating member is canceled by SCF for non-payment of premium, enrollment shall become null and void and neither premium nor losses for the period will be included in the Association's dividend calculation.

6) Participating policyholders removed from the ASP due to high losses will not be eligible for enrollment in any other ASP for at least one year.

7) This enrollment shall remain in effect unless canceled by SCF, the association, the member, or if the member transfers to a different ASP.

8) Retrospective Rating, Assigned Risk, Self-Rater, deductible program, Professional Employer Organization (PEO) and SCF Casualty Insurance Company policyholders are not eligible to participate in an ASP.

It is understood that: This application is made by and between SCF Arizona, 3030 N. 3rd St., Phoenix, AZ, 85012, on behalf of itself and its subsidiaries, and the policyholder (name and address above). By signing below, the policyholder accepts this application in full and understands that it will be reviewed for eligibility by SCF Arizona and the above named association.

I have read and accept all of the terms and conditions set forth on this ASP Enrollment Application.

Authorized Rep. - Name of Owner, Partner, Corp. Off.		Title
Contact Email		Contact Phone

By clicking on "I Agree" below I am confirming and declaring that all information that I am providing in this ASP Enrollment Application is true and complete. I am also confirming that I understand that SCF Arizona is materially and justifiably relying upon the information that I am providing to evaluate my eligibility for particiaption in the ASP. I acknowledge that if the information I provided is untrue or incomplete, I may be removed from the ASP. I understand and agree to the rights and obligations of participating in an ASP as described in this application.