Swif 429 Form – Fill Out and Use

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)

APPLICATION FOR WORKERS’ COMPENSATION INSURANCE

1.Business name Mailing address

PA primary operating location

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.

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＃

List each owner separately:

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:

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.

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

*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)

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)