Swif Application Details

Are you looking for a way to improve the tone of your voice? The Swif 429 form may be just what you need. This form helps to improve the tone and clarity of your voice by providing exercises that target problem areas. With regular practice, you can see a noticeable improvement in your vocal quality.

This general guide will let you figure out how much time it will take you to fill out swif 429 form, how many pages it has, and a few additional unique details about the form.

QuestionAnswer
Form NameSwif 429 Form
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namespennsylvania swif, pa application workers, pennsylvania workers insurance, pa form workers compensation insurance search

Form Preview Example

DEPARTMENT OF LABOR & INDUSTRY STATE WORKERS’ INSURANCE FUND

APPLICATION FOR

WORKERS’ COMPENSATION

INSURANCE COVERAGE

PLEASE READ

Lw# lv# pdqgdwru|# xqghu# wkh# Shqqv|oydqld# Zrunhuvᄊ# Frpshqvdwlrq# dqg# Rffxsdwlrqdo# Glvhdvh# Dfwv# wkdw# dq#

employer carry workers’ compensation insurance. Failure to comply with these laws subjects employers wr# odzvxlwv# e|# hpsor|hhv# dqg# fulplqdo# survhfxwlrq1# Vxfk# survhfxwlrqv# frxog# uhvxow# lq# vxevwdqwldo# ﾿qhv/#

imprisonmentorboth.Inaddition,basedupontheWorkers’Compensation Act, the carrier must have an insurable interest to write a workers’ compensation policy; having no employees constitutes no insurable interest. State Workers’ Insurance Fund (SWIF) is prohibited from issuing a policy on an “if any” basis.

COMPLETE AND SIGN THE APPLICATION

Submit the application by mail to State Workers’ Insurance Fund, 100 Lackawanna Avenue, PO Box 5100, Scranton, PA 18505-5100.

Should you have any questions about the application or coverage, you may contact Customer Service at 570-963-4635.

For policies less than $2,000 in premium, total payment is required. For policies greater than $2,000 in premium, SWIF requires a payment of 25 percent of the premium OR the minimum premium, whichever is greater, including the Employer’s Assessment Fee, Terrorism Fee and Commercial Catastrophe Fee. Under certain circumstances, at SWIF’s discretion, total premium may be required before coverage will be incepted. (see “Instructions” www.dli.pa.gov/swif select Underwriting)

Please make checks (black or blue ink only) and money orders payable to “SWIF.” When you provide a check as payment, you authorize SWIF either to use information from your check to make a one-time electronic fund transfer (EFT) from your account or to process the payment as a check transaction. Note: SWIF does not accept cash payments.

SWIF does not offer waiver of subrogation endorsements.

If you are a sole proprietor, partners of a partnership or members of an LLC, complete the Voluntary Election of Coverage form POL115A/51A indicating your choice to accept or decline coverage.

Li#|rx#duh#d#frusrudwh#ri﾿fhu#dqg2ru#rzqhu#fkrrvlqj#wr#zdlyh#|rxu#uljkwv/#frpsohwh#dqg#vxeplw#wkh#vljqhg# ri﾿fhu#h{fhswlrq#irupv#OLEF053<#&#OLEF05461

All required forms and resources may be found either on the SWIF website www.dli.pa.gov/swif or as vshfl﾿hg#lq#wklv#dssolfdwlrq1

Any party who willfully makes a false statement or representation, deliberately conceals any material fact, or engages in any other fraudulent scheme or device, for the purpose of obtaining or attempting to obtain, or for the purpose of aiding or abetting any person to obtain insurance in the State Workers’ Insurance Fund (SWIF) at less than the proper rate for such insurance, or payment out of SWIF to which such person is not entitled, is guilty of a crime. Providing false information on this application or engaging in fraud can lead to the applicant being disbarred from being awarded a contract with the commonwealth for as long as three years, and may further lead to disbarment with local governments in the commonwealth.

I understand and will comply with the information on this page

BUSINESS NAME

SIGNATURE#+Rzqhu2Frusrudwh#Ri﾿fhu2Sduwqhu,######################################################Gdwh

NOTE: Signatures on page one and on page seven should match.

SWIF-429 REV 08-16 (Page 1)

FOR OFFICE USE ONLY: Application #

 

Check #

 

Amount $

 

 

 

 

 

 

 

APPLICATION FOR WORKERS’ COMPENSATION INSURANCE

1.Business name Mailing address

PA primary operating location

 

County

 

Telephone

 

 

 

 

Business Fax

 

 

Email

 

 

 

 

 

Website

 

 

51

Ihghudo#Hpsor|hu#Lghqwl﾿fdwlrq#Qxpehu

 

 

#+dfwlyh#IHLQ#lv#uhtxluhg;#www.irs.gov to apply)

a.If new, date applied

b.List the name and FEIN of each additional business owned and operated to be included in this policy.

c.If multiple entities are to be insured on one policy, submit an ERM-14 form to identify each business.

d.Has any principal applicant had a previous business that was insured by SWIF under a different

qdph/#hqwlw|#ru#IHLQB#Li#vr/#lqfoxgh#qdphv#ri#suhylrxv#exvlqhvv+hv,/#qdphv#ri#rzqhuv2ri﾿fhuv#ri#wkh business(es) and FEIN(s):

STOP! YOU MUST COMPLETE TABLE A OR TABLE B ACCORDING TO YOUR TYPE OF ENTITY!

FAILURE TO COMPLETE THIS SECTION IN ITS ENTIRETY

WILL CAUSE YOUR APPLICATION TO BE RETURNED WITH NO COVERAGE.

3. Indicate the type of business (check all that apply)

Complete Table A - Sole proprietors, partners of

Individual/Sole Proprietor

a partnership or LLP, members of an LLC electing

 

Partnership

or declining to be included under the PA Workers’

Limited Liability Company

Compensation Act must complete form POL 115 or the

Limited Liability Partnership

online form SWIF-51 Voluntary Election of Coverage.

 

Corporation (S or C)

Complete Table B# 0# Dq# h{hfxwlyh# ri﾿fhu# ri# d#

Qrq0sur﾿w#Frusrudwlrq

corporation, if eligible, may elect to be exempt

Professional Employer Organization

under the PA WC Act by completing and submitting

irupv#OLEF#53<#&#5461#Li#qrw#vxeplwwhg/#rzqhuv2

Temporary Agency

ri﾿fhuv# zloo# uhpdlq# lqfoxghg# iru# wkh# hqwluh# srolf|#

Other (Please specify, i.e. PEO client)

term.

 

 

 

 

 

 

 

 

Ownership for Sole Proprietor / Partner / LLP/LLC - List each owner separately

 

 

 

 

 

TABLE A: Has this business entity been insured with SWIF before? Yes

 

No

 

 

 

 

 

 

 

 

Iluvw#&#Odvw#Qdph

Sole Proprietor / Partner Member

SS#

%Class Ownership Code

Active Covered Y/N Y/N

QRWH=#DOO#LQFRPSOHWH#DSSOLFDWLRQV#RU#WKRVH#ZLWKRXW#WKH#SURSHU#UHPLWWDQFH#ZLOO#EH#UHWXUQHG#

WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU SUBMIT

SWIF-429 REV 08-16 (Page 2)

APPLICATION FOR WORKERS’ COMPENSATION INSURANCE

Rzqhuvkls2Wlwoh#iru=#V#ru#F#Frusrudwlrq2#Qrq0Surilw#

TABLE B: Has this business entity been insured with SWIF before? Yes

No

List each owner separately:

First and Last Name

Corporate

Riilfhu Title

SS#

%

Ownership

Class Active Covered

Code Y/N Y/N

d1# Gdwh#duwlfohv#﾿ohg

b. State

4. Is this business currently in the process of liquidation or termination?

No

Yes - explain:

51# Kdv#wklv#exvlqhvv#hyhu#﾿ohg#iru#edqnuxswf|B

No

\hv#0#gdwh#﾿ohg=#

Is this business currently in bankruptcy?

No

Yes - Must#hqforvh#d#frs|#ri#wkh#shwlwlrq#dv#﾿ohg#lq#edqnuxswf|#frxuw/#lqfoxglqj#doo#dwwdfkphqwv1#

6. Audit Contact

Contact person

Address

Telephone

Email

7. Safety/Loss Control

Contact person

Address

Telephone

Email

QRWH=#DOO#LQFRPSOHWH#DSSOLFDWLRQV#RU#WKRVH#ZLWKRXW#WKH#SURSHU#UHPLWWDQFH#ZLOO#EH#UHWXUQHG#

WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU

SUBMIT SWIF-429 REV 08-16 (Page 3)

APPLICATION FOR WORKERS’ COMPENSATION INSURANCE

8. Has this business entity had previous workers’ compensation insurance coverage in Pennsylvania?

No

Yes - answer the following completely: a. Business name

b. Carrier name c. Policy number

g1 Gdwh#fdqfhoohg2h{sluhg

e. Anniversary date

f.Premium

g.Carrier information for the previous three(3) years:

Carrier

 

Premium

 

Year

Carrier

 

Premium

 

Year

Carrier

 

Premium

 

Year

IF YOUR PREMIUM IS IN EXCESS OF $20,000, ATTACH FIVE YEARS OF DETAILED LOSS AND PREMIUM HISTORY

h. Pennsylvania Compensation Rating Bureau #

###l1 H{shulhqfh#prgl﾿fdwlrq2phulw #########################################################Gdwh

j. Home Improvement Contract number (HIC#)

9.Has workers’ compensation coverage ever been cancelled for this business entity?

No

Yes - explain:

10.Provide a COMPLETE, DETAILED#mre#ghvfulswlrq#ri#doo#zrun#shuiruphg#e|#fodvvl﾿fdwlrq#ri#|rxu#gd|0wr0gd|# rshudwlrqv/#lqfoxglqj#wkh#mre#gxwlhv#ri#wkh#frusrudwh#ri﾿fhuv#dqg2ru#rzqhuv1#+Dwwdfk#dq#dgglwlrqdo#vkhhw/#li# necessary.)

Provide the following where applicable on a separate page: a. List of clerical employees and their job duties

#####e1#Yroxqwhhu#Iluh#Ghsduwphqw#Urvwhu#+Dfw#79,#dqg#Yroxqwhhu#Iluhpdq#H{srvxuh#irup/#zzz1sfue1frp

c.List of the names and Social Security numbers for any domestic workers. Include number of hours worked per week per employee (part time - under 20 hours; full time - 20 hours or more).

d.Approval to Exempt Certain Religious Members (form LIBC-14C) www.wcais.pa.gov

###h1 Ohwwhu#ri#Fhuwl﾿fdwlrq#Dssurydo#ri#Zrunsodfh#Vdihw|#Frpplwwhh#iurp#wkh#Exuhdx#ri#Zrunhuvᄊ

Compensation (Safety Credit)

441#Grhv#wklv#exvlqhvv#hqwlw|#hqjdjh#ru#xvh#dq|#ri#wkh#iroorzlqj=

Privately-owned or leased aircraft

Maritime/harbor workers (NOTE: SWIF does not offer Jones Act coverage)

X1V1#Ghsduwphqw#ri#Ghihqvh#frqwudfwv/#rxwvlgh#X1V1#Whuulwrulhv

N/A

QRWH=#DOO#LQFRPSOHWH#DSSOLFDWLRQV#RU#WKRVH#ZLWKRXW#WKH#SURSHU#UHPLWWDQFH#ZLOO#EH#UHWXUQHG#

WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU SUBMIT

SWIF-429 REV 08-16 (Page 4)

APPLICATION FOR WORKERS’ COMPENSATION INSURANCE

451#Grhv#wklv#exvlqhvv#xwlol}h#wkh#vhuylfhv#ri#vxefrqwudfwruv/#rzqhu0rshudwruv/#dqg2ru#lqghshqghqw#frqwudfwruv#

in the operation of your business? No

\hv# 0 Surylgh# frs|# ri# fhuwl﾿fdwhv# ri# lqvxudqfh# +FRL,# iru# doo# vxefrqwudfwruv# surylqj# zrunhuvᄊ#

compensation coverage in Pennsylvania and a copy of the signed contracts between the applicant and the subcontractor(s) required per Act 72. If valid COI’s cannot be provided, submit a completed Independent Contractor Questionnaire form (SWIF-831). Owners/operators must complete the trucking Questionnaire form, (SWIF-832). Any subcontractors that do not carry workers’ compensation may be included in coverage upon review. Also note that SWIF reserves the right to make a determination on the employment status of these individuals and may require them to be included as employees for workers’ compensation purposes.

13. Liability limits are set to state minimum ($100K/$100K/$500K);

IRU#LQFUHDVHG#OLPLWV##□#$500K/$500K/$500K □#'4ploolrq2'4ploolrq2'4ploolrq

14.Payroll: Additional information such as rates, class codes and instructions to estimate your premium may

be found on the website: www.dli.pa.gov/swif#QRWH=#Sd|uroo#iru#ri﾿fhuv2rzqhuv#fkrrvlqj#h{hpswlrq#lq# question #3 should be excluded.

Class Code or

Ghvfulswlrq#

Number of Employees

Estimated Payroll

per Class

for One Year Term

 

 

Class Rate per

$100 payroll

Estimated Premium

15.a. If this business entity uses temporary workers provided through vwdi﾿qj#djhqflhv, include

Fhuwl﾿fdwhv#ri#Lqvxudqfh#iurp#hdfk#djhqf|#xvhg1#

b.If this business entity contracts with a Surihvvlrqdo#Hpsor|hu#Rujdql}dwlrq#+SHR,#iru#ohdvhg#zrunhuv, provide a copy of signed contracts and/or agreements from each client as well as a list of employees

per contract.

c. If this business entity is a Surihvvlrqdo#Hpsor|hu#Rujdql}dwlrq#+SHR,, include the requirements

which can be found on the SWIF Homepage resources link for PEO requirements (www.dli.pa.gov/swif) d. If this business entity is a whpsrudu|#djhqf|, complete and sign the Dowhuqdwh#Hpsor|hu

Hqgruvhphqw#Zrunvkhhw which is located on the SWIF webpage, under “Forms” at

zzz1gol1sd1jry2vzli1#VZLI#pxvw#eh#qrwl﾿hg#ri#doo#Dowhuqdwh#Hpsor|huv#+whpsrudu|

folhqwv,#lpphgldwho|#xsrq#dftxlvlwlrq#gxulqj#wkh#srolf|#whup1 If any Alternate Employer is

#####dftxluhg#gxulqj#wkh#srolf|#whup#zlwkrxw#qrwl﾿fdwlrq#wr#VZLI/#fodlpv#dwwulexwhg#wr#wkrvh#vshfl﾿f#folhqwv#

will be denied.

* Note that it is the policy of the State Workers’ Insurance Fund to provide policy information only to the policyholder; that is, that only the insured and/or the authorized agent may request the deryh#lqirupdwlrq1Wklv#lqfoxghv#uhtxhvwlqj#Fhuwl﾿fdwhv#ri#Lqvxudqfh1#VZLI#grhv#qrw#wdnh#uhtxhvwv from third parties.

QRWH=#DOO#LQFRPSOHWH#DSSOLFDWLRQV#RU#WKRVH#ZLWKRXW#WKH#SURSHU#UHPLWWDQFH#ZLOO#EH#UHWXUQHG#

WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU SUBMIT

SWIF-429 REV 08-16 (Page 5)

APPLICATION FOR WORKERS’ COMPENSATION INSURANCE

16. Payment Terms

Policy premiums less than $2,000

WRWDO#SUHPLXP#UHTXLUHG1#

 

 

Policy premiums $2,000 to $10,000

25% of the total premium, or the minimum

 

premium whichever is greater; * with the remaining

 

balance due in four equal installments.

 

 

Policy premiums over $10,000

25% of the total premium, or the minimum

 

premium whichever is greater; * with the remaining

 

balance due in ten (10) equal installments.

 

 

*Total premium includes the Employer’s Assessment Fee, Terrorism Fee and Commercial Catastrophe Fee

Uhtxhvwhg#lqfhswlrq#gdwh#ri#fryhudjh=#

NOTE: COVERAGE WILL NOT BE BOUND PRIOR TO THE DATE AFTER RECEIPT OF A

COMPLETED SWIF APPLICATION WITH REQUIRED PREMIUM.

PLEASE REVIEW FOR COMPLETENESS PRIOR TO SUBMISSION.

17.Contract Conditions

###d1#Fryhudjh#zloo#ehfrph#hiihfwlyh#dw#45=34#d1p1#rq#wkh#gd|#vshfl﾿hg#rq#wkh#zrunhuvᄊ#frpshqvdwlrq#srolf|

issued by SWIF. In order for an application to be deemed acceptable for review and coverage, SWIF pxvw#uhfhlyh#d#frpsohwh#dqg#surshuo|#vljqhg#dssolfdwlrq#dqg#wkh#vshfl﾿hg#suhplxp#gxh1

b. The application, including any subcontractor information elicited in Item 12 of the application, must

eh# surshuo|# dqg# ixoo|# frpsohwhg# dqg# vljqhg# e|# dq# rzqhu/# ru# sduwqhu/# ru# d# frusrudwh# ri﾿fhu1# Wkh #Frqvwuxfwlrq#Zrunsodfh#Plvfodvvl﾿fdwlrq#Dfw#+Dfw#:5,#ixuwkhu#hvwdeolvkhg#d#gh﾿qlwlrq#ri#dq#ᄈLqghshqghqw

Contractor” for purposes of Workers’ Compensation as of February 10, 2011 and information regarding such can be found at www.dli.pa.gov/swif

c.The premium quoted is based upon the nature of the operations and the estimated payroll disclosed by the employer in this application. The employer shall furnish SWIF with proper notice of any changes in the nature of its operations or its estimated payroll; such changes may result in an increase or decrease in the premium due under this policy. The employer agrees to keep an accurate record of employees and payroll expenditures, and to report injuries and occupational diseases to the State Workers’ Insurance Fund immediately.

d.SWIF requires the disclosure of accurate and legitimate payroll records. Such payroll records must include, but are not limited to, a list of each employee’s Social Security number or I-9 forms. The determination of proper premium payments is dependent upon the accuracy of such records. Any failure to provide accurate and legitimate payroll records, at any time, will be considered a material breach entitling SWIF to either rescind the contract to insure, refuse to insure, or cancel the policy.

e.The State Workers’ Insurance Fund may conduct underwriting visits and/or audits during regular business hours during the policy period and within three (3) years after the policy ends. Information developed

e|#wkh#xqghuzulwlqj#ylvlw#ru#dxglw#zloo#eh#xvhg#wr#ghwhuplqh#wkh#hvwlpdwhg#ru#﾿qdo#suhplxp1#Li#lw#lv determined that additional premium is due, you will be billed accordingly.

f.When any claim for a temporary worker occurs at a client/Alternate Employer’s location of which SWIF kdv#qrw#ehhq#suhylrxvo|#qrwl﾿hg/#wkh#fodlp#zloo#eh#ghqlhg1

g.Employees hired in and working in another state cannot be covered by the Pennsylvania State Workers’ Insurance Fund.

QRWH=#DOO#LQFRPSOHWH#DSSOLFDWLRQV#RU#WKRVH#ZLWKRXW#WKH#SURSHU#UHPLWWDQFH#ZLOO#EH#UHWXUQHG#

WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU SUBMIT

SWIF-429 REV 08-16 (Page 6)

APPLICATION FOR WORKERS’ COMPENSATION INSURANCE

THE APPLICATION MUST BE SIGNED BY AN OWNER, A PARTNER OR A CORPORATE OFFICER

AND RETURNED WITH YOUR PAYMENT.

18.I certify that all information provided in this document is correct and complete. I acknowledge that false statements in this document are punishable pursuant to 18 Pa. C.S. §4904 (relating to Unsworn

Idovl﾿fdwlrq# wr# Dxwkrulwlhv,/# 4;# Sd1# F1V1# ニ744:# +uhodwlqj# wr# Lqvxudqfh# Iudxg,# dqg# ::# S1V1# ニ# 436<15

(relating to the Workers’ Compensation Act). A person who knowingly makes a false statement or nqrzlqjo|#zlwkkrogv#lqirupdwlrq#pd|#eh#vxemhfw#wr#d#﾿qh/#lpsulvrqphqw#dqg#uhvwlwxwlrq1

SIGNATURE

 

DATE

Sulqw#Ixoo#Qdph#

19.BROKER OF RECORD LETTER:#Wkh#iroorzlqj#eurnhu2djhqw#kdv#ehhq#ghvljqdwhg#dv#wkh#ri﾿fldo#ᄈEurnhu of Record”. The following information must be completed and signed by BOTH the broker/agent and the applicant. No additional Broker of Record Letter is required.

--QRWH=#Eurnhudjhv#duh#QRW#dxwkrul}hg#wr#lvvxh#Fhuwl﾿fdwhv#ri#Lqvxudqfh#rq#ehkdoi#ri#wkh# Vwdwh#Zrunhuvᄊ#Lqvxudqfh#Ixqg1#Doo#FRLᄊv#pxvw#eh#lvvxhg#e|#uhtxhvw#wkurxjk#VZLI#rqo|1#

GR#QRW#LVVXH#FHUWLILFDWHV#RQ#EHKDOI#RI#VZLI#rq#DFRUG#irupv#ru#dq|#rwkhu#grfxphqw1#

BROKER/AGENT NAME OR INSURANCE AGENCY

Name

Address

Telephone

 

 

Fax

 

Email

 

 

SIGNATURE OF APPLICANT

 

 

 

 

 

Title

 

SIGNATURE OF BROKER

 

 

 

 

 

 

 

Print name

 

 

 

 

 

 

 

Gdwh#

 

20.FINANCE COMPANY LETTER:# Wkh# iroorzlqj# ﾿qdqfh# frpsdq|# kdv# ehhq# ghvljqdwhg# dv# wkh# ri﾿fldo ᄈIlqdqfh#Frpsdq|1ᄡ#Wkh#iroorzlqj#lqirupdwlrq#pxvw#eh#frpsohwhg#dqg#vljqhg#e|#wkh#﾿qdqfh#frpsdq| and the Insured.

ATTACH COMPLETED, SIGNED FINANCE AGREEMENT

NAME OF FINANCE COMPANY

Name

Address

Telephone

 

 

Fax

 

Email

 

 

VLJQDWXUH#ri#Frpsdq|#Uhsuhvhqwdwlyh#

 

 

 

Title

 

SIGNATURE OF APPLICANT

 

 

 

 

 

 

 

 

Print name

 

 

 

 

 

 

 

Gdwh#

 

QRWH=#DOO#LQFRPSOHWH#DSSOLFDWLRQV#RU#WKRVH#ZLWKRXW#WKH#SURSHU#UHPLWWDQFH#ZLOO#EH#UHWXUQHG#

WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU

SUBMIT SWIF-429 REV 08-16 (Page 7)

STATE WORKERS’ INSURANCE FUND

Auxiliary aids and services are available upon request to individuals with disabilities.

Equal Opportunity Employer/Program

SWIF-429 REV 08-16 (Page 8)

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .