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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.
Question | Answer |
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Form Name | Swif 429 Form |
Form Length | 8 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 2 min |
Other names | pennsylvania swif, pa application workers, pennsylvania workers insurance, pa form workers compensation insurance search |
DEPARTMENT OF LABOR & INDUSTRY STATE WORKERS’ INSURANCE FUND
APPLICATION FOR
WORKERS’ COMPENSATION
INSURANCE COVERAGE
PLEASE READ
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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
Should you have any questions about the application or coverage, you may contact Customer Service at
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
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#rifhu#dqg2ru#rzqhu#fkrrvlqj#wr#zdlyh#|rxu#uljkwv/#frpsohwh#dqg#vxeplw#wkh#vljqhg# rifhu#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 vshflhg#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#Rifhu2Sduwqhu,######################################################Gdwh
NOTE: Signatures on page one and on page seven should match.
FOR OFFICE USE ONLY: Application # |
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APPLICATION FOR WORKERS’ COMPENSATION INSURANCE
1.Business name Mailing address
PA primary operating location
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Business Fax |
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#+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
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#rzqhuv2rifhuv#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 |
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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 |
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Corporation (S or C) |
Complete Table B# 0# Dq# h{hfxwlyh# rifhu# ri# d# |
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corporation, if eligible, may elect to be exempt |
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Professional Employer Organization |
under the PA WC Act by completing and submitting |
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Temporary Agency |
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Other (Please specify, i.e. PEO client) |
term. |
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Ownership for Sole Proprietor / Partner / LLP/LLC - List each owner separately |
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TABLE A: Has this business entity been insured with SWIF before? Yes |
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No |
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Sole Proprietor / Partner Member
SS#
%Class Ownership Code
Active Covered Y/N Y/N
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WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU SUBMIT
APPLICATION FOR WORKERS’ COMPENSATION INSURANCE
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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
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b. State
4. Is this business currently in the process of liquidation or termination?
No
Yes - explain:
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No
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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
7. Safety/Loss Control
Contact person
Address
Telephone
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WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU
SUBMIT
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
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e. Anniversary date
f.Premium
g.Carrier information for the previous three(3) years:
Carrier |
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Year |
Carrier |
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Premium |
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Year |
Carrier |
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Premium |
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Year |
IF YOUR PREMIUM IS IN EXCESS OF $20,000, ATTACH FIVE YEARS OF DETAILED LOSS AND PREMIUM HISTORY
h. Pennsylvania Compensation Rating Bureau #
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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|#fodvvlfdwlrq#ri#|rxu#gd|0wr0gd|# rshudwlrqv/#lqfoxglqj#wkh#mre#gxwlhv#ri#wkh#frusrudwh#rifhuv#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
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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
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Compensation (Safety Credit)
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Maritime/harbor workers (NOTE: SWIF does not offer Jones Act coverage)
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N/A#
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WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU SUBMIT
APPLICATION FOR WORKERS’ COMPENSATION INSURANCE
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in the operation of your business? No
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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
13. Liability limits are set to state minimum ($100K/$100K/$500K);
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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#rifhuv2rzqhuv#fkrrvlqj#h{hpswlrq#lq# question #3 should be excluded.
Class Code or
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Number of Employees |
Estimated Payroll |
per Class |
for One Year Term |
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Class Rate per
$100 payroll
Estimated Premium
15.a. If this business entity uses temporary workers provided through vwdiqj#djhqflhv, include
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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
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folhqwv,#lpphgldwho|#xsrq#dftxlvlwlrq#gxulqj#wkh#srolf|#whup1 If any Alternate Employer is
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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#Fhuwlfdwhv#ri#Lqvxudqfh1#VZLI#grhv#qrw#wdnh#uhtxhvwv from third parties.
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WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU SUBMIT
APPLICATION FOR WORKERS’ COMPENSATION INSURANCE
16. Payment Terms
Policy premiums less than $2,000 |
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Policy premiums $2,000 to $10,000 |
25% of the total premium, or the minimum |
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premium whichever is greater; * with the remaining |
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balance due in four equal installments. |
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Policy premiums over $10,000 |
25% of the total premium, or the minimum |
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premium whichever is greater; * with the remaining |
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balance due in ten (10) equal installments. |
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*Total premium includes the Employer’s Assessment Fee, Terrorism Fee and Commercial Catastrophe Fee
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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
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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#vshflhg#suhplxp#gxh1
b. The application, including any subcontractor information elicited in Item 12 of the application, must
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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
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|#qrwlhg/#wkh#fodlp#zloo#eh#ghqlhg1
g.Employees hired in and working in another state cannot be covered by the Pennsylvania State Workers’ Insurance Fund.
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WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU SUBMIT
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
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(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 |
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DATE |
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19.BROKER OF RECORD LETTER:#Wkh#iroorzlqj#eurnhu2djhqw#kdv#ehhq#ghvljqdwhg#dv#wkh#rifldo#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.
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BROKER/AGENT NAME OR INSURANCE AGENCY
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SIGNATURE OF APPLICANT |
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SIGNATURE OF BROKER |
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Print name |
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20.FINANCE COMPANY LETTER:# Wkh# iroorzlqj# qdqfh# frpsdq|# kdv# ehhq# ghvljqdwhg# dv# wkh# rifldo 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
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VLJQDWXUH#ri#Frpsdq|#Uhsuhvhqwdwlyh# |
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SIGNATURE OF APPLICANT |
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Print name |
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WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU
SUBMIT
STATE WORKERS’ INSURANCE FUND
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program