WC Form 18 is a form used to report wage and hour violations. It is used to document the number of hours worked, overtime hours, and pay rate. Violations can be reported to the Department of Labor, state labor department, or other agency. Filing a WC Form 18 may help ensure that employees receive the wages they are owed.
| Question | Answer |
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| Form Name | Wc Form 18 |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | alabama form self pdf, form for unemployment self employed alabama, alabama dot self certification form, alabama form self |
WC Form 18
Revised 10/12
EMPLOYER’S APPLICATION FOR SELF INSURANCE
(Submit one completed copy)
CONFIDENTIAL
To the DEPARTMENT OF LABOR:
The undersigned, an employer subject to the provisions of the Alabama Workers’ Compensation law, as last amended, hereby applies for the privilege of
1.Name of Applicant _______________________________________________________________________
2.Address
P.O. Box
(Number) |
(Street) |
(City or Town) |
(County) |
(State) (Zip) |
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Telephone ( ) |
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AL U.C. Number |
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EMPLOYER IDENTIFICATION NUMBER
3. The applicant is
(State whether individual,
4.briefly the general character of the operations performed and the articles manufactured or compounded at or away from the plant or premises of the applicant.
5.Description of employment:
Location of Plant or Plants
Kind of Equipment
Estimated average |
Estimated average |
Estimated payroll of all |
number of employees at |
number of employees in |
Alabama employees for |
all points |
Alabama |
ensuing year |
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6. If a Corporation or Limited Partnership list below names of officers, directors, and residence of each:
NAME
OFFICIAL TITLE
ADDRESS
7.If a Limited Partnership, give date of formation and duration
8.If a Partnership, list below names of members and residence of each
9.If Individual, give name and residence
10.If a Corporation, answer the following: Chartered under the laws of the State of
Date of incorporation_____________________ Authorized Capital Stock: (Common) $
(Preferred) $
11.Is applicant a subsidiary? ________ Give name and address of parent company
(Subsidiaries must have separate applications and indemnity agreements)
12. If foreign corporation, give address of Home Office
13.Date when
14.Are you now complying with Section
15.What is the expiration date of your present policy?__________________________________
16.Are you now, or have you been within the past three years, an assigned risk for workers’ compensation insurance? (Give dates and details on separate page, if necessary)
17.As a
18. Past |
__________ ____________ |
____________ |
Number of deaths |
__________ |
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____________ |
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Alabama Workers’ Compensation Premiums |
$_________ |
$___________ |
$____________ |
Alabama Workers’ Comp Incurred Losses |
$_________ |
$___________ |
$____________ |
19.Are there any outstanding unpaid judgments subject to execution rendered against the applicant under the provisions of the Workers’ Compensation Law, as last amended? (Give amounts and details on separate page, if necessary)
20.Applicant must attach audited or certified financial reports for the prior three years of operation.
21.Applicant must submit a $500.00 application fee with each application submitted.
Make payable to: |
Department of Labor Workers’ Compensation Administrative Trust Fund. |
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22. |
Name of excess insurance carrier (if any) |
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Amount of Retention $ |
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Specific, Aggregate, or both? |
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23. |
Relate facts, covering past three years: |
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Year Ending |
Sales (Omit cents) |
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Expenses (including |
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Payroll |
Profit or Loss |
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payroll) |
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(Specify) |
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20 |
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24. |
Has the applicant, or its parent corporation, every filed for bankruptcy? |
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If yes, give details on separate sheet. |
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AGREEMENT CONDITIONS
25.In consideration of the approval of this application, the applicant expressly agrees:
(a)That this privilege may be revoked at any time in the discretion of the Secretary of Labor as provided in Section
(b)That the applicant will promptly furnish adequate hospital, medical, surgical, and burial benefits within the limits of the Law.
(c)That the applicant will discharge liability for compensation to injured employees or their dependents in accordance with said Law’s requirements.
(d)That reports will be promptly furnished the Department in strict accordance with Sections
(e)That the applicant will not solicit, receive or collect from his employees, any part of the cost to him of operating under this Law.
(f)That the applicant will promptly notify the Department upon insuring his workers’ compensation liability with a private casualty insurance company, thereby cancelling his
(g)That a copy of the company’s annual report, or statement of assets and liabilities, will be mailed to the Department at the close of each fiscal year, as evidence of continued financial ability to
(Signed)________________________________________
(Title)__________________________________________ STATE
OF ________________________________ COUNTY OF ______________________________
__________________________________, being first duly sworn, appeared personally and declared that the
facts set forth in the foregoing application are true to the best of his knowledge, information and belief. Subscribed and sworn to before me, this __________ day of __________________________, 20_____
(Notary Public) (SEAL) My commission
expires on the __________ day of _________________________, 20_____