State Workers Insurance Application
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Application For
Workers’ Compensation
Insurance Coverage
INSTRUCTIONS:
•
Answer all questions completely and correctly. Please type or print.
Clear All Fields
•
Sign the application, as indicated in Item 18.
•
If represented by a Broker/Agent, complete Item 19.
•
Mark “N/A” when not applicable.
•
Return the completed application to: State Workers’ Insurance Fund, 100 Lackawanna Avenue, P.O. Box 5100,
Scranton, PA 18505-5100, telephone 570-963-4635, fax 570-941-2109.
•
Coverage will become effective as of the date set forth on the Policy of Insurance.
1. Business Name
Mailing Address
(IF R.D., R.R., OR P .O. BOX, LIST GEOGRAPHICAL LOCATION: INCLUDE SUITE, FLOOR OR APT. NO., IF APPLICABLE)
PA Primary Operating Location
(ATTACH LIST WITH ADDRESSES OF ALL PA OPERATING LOCATIONS)
County
Telephone No. you can be reached at during the day
AREA CODE
Business Fax No. _______________________________ E-Mail __________________________________________
2. Federal ID No.
a. If new, date applied for
b. List the names and Federal identification numbers of additional businesses owned and operated to be
included in this policy.
NAME
FED. ID NO.
NAME
FED. ID NO.
c. If multiple insureds are to appear on one policy, please submit Form ERM-14 to identify each business.
■ Leasing Company
■ Temporary Agency
■ Both
■ N/A
3. a. Are you a:
■ Individual
b. Type of Business:
If Individual, S.S. No.
■ Corporation
■ Partnership
■ Non-profit
■ Other
4. Corporate Entity Only:
a. Date articles filed
b. State
■ Yes
■ No
5. Are you currently in the process of liquidation or termination of this business?
If yes, explain
6. Has the business ever filed for bankruptcy?
■ Yes
■ No If yes, date filed
■ Yes
■ No
Is the business currently in bankruptcy?
If yes, YOU MUST enclose a copy of the petition as
filed in bankruptcy court, including all attachments.
SWIF-429 REV 4-08 (Page 1)
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Parent category: Business