State Workers Insurance Application Page 2
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7.
Audit Information (Address where payroll records are kept):
a. Contact Person
b. Telephone No.
AREA CODE
c. Audit Address
(IF R.D., R.R., OR P .O. BOX, LIST GEOGRAPHICAL LOCATION: INCLUDE SUITE, FLOOR OR APT. NO., IF APPLICABLE)
d. County
8. Have you had previous workers’ compensation insurance coverage in Pennsylvania?
■ Yes
■ No
If yes, answer the following completely:
a. Business Name
b. Carrier Name
c. Policy No.
d. Date Cancelled/Expired
e. Anniversary Date
f. Premium
g. Carrier information for the previous three (3) years: (NOTE: IF YOUR PREMIUM IS IN EXCESS OF $50,000.00,
FIVE YEARS DETAILED LOSS HISTORY MUST BE ATTACHED.)
CARRIER POLICY NO. PERIOD PREMIUM
C ARRIER POLICY NO. PERIOD PREMIUM
CARRIER POLICY NO. PERIOD PREMIUM
h. Pennsylvania Compensation Rating Bureau No.
i. Experience Modification
j. Experience Modification Effective Date
■ Yes
■ No
9. Have you ever been cancelled?
If yes, explain
10. Please provide a COMPLETE, DETAILED job description of all work performed in Pennsylvania, including the
job duties of the corporate officers and/or owners. (Attach an additional sheet, if necessary.)
■ Yes
■ No
11. Do you use privately-owned or leased aircraft in the operation of the business?
If yes, total number of seats for all aircraft
12. Do you utilize the services of subcontractors, owner-operators, and/or independent contractors in the
■ Yes
■ No
operation of your business?
If yes, please provide Certificates of Insurance evidencing the fact that there is workers’ compensation
insurance in place for those workers. If no insurance certificate is available, questionnaires must be
completed and submitted before any workers’ compensation insurance policy can be issued. The State
Workers’ Insurance Fund reserves the right to make a determination on the employment status of these
individuals and may decide to include them as employees for workers’ compensation purposes. If you
are an employer who utilizes sole proprietor(s) and the sole proprietor(s) does not have workers'
SWIF-429 REV 4-08 (Page 2)
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