State Workers Insurance Application Page 3
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4compensation insurance coverage of their own, you will be considered as the sole proprietor(s)' employer
and charged accordingly as to the operations performed when the State Workers' Insurance Fun completes
an audit of your policy, unless there is definitive evidence that the sole proprietor(s) is an independent
contractor. Workers' compensation coverage for sole proprietor(s) is available through the State Workers'
Insurance Fund.
13. Corporate Officer/Names of Partners: (NOTE: An Executive Officer of a corporation, if eligible, may elect to be
exempt from the Pennsylvania Workers’ Compensation Act. All Corporate Officer Exemption Requests should
be directed to the State Workers’ Insurance Fund. Otherwise all payroll for covered officers must be included in
Item 14 below. This section MUST BE completed in its entirety or your application may not be accepted. If you
are a sole proprietor, you must check either Yes or No to indicate whether you are requesting coverage as a
sole proprietor.
ACTIVE
COVERED
% OF OWNERSHIP
CLASS
TITLE
FIRST NAME
M
LAST NAME
S. S. NO.
(Y/N)
(Y/N)
OR STOCK
CODE
14.
ENTER ESTIMATED PAYROLL
DESCRIBE KIND OF TRADE,
ENTER ESTIMATED AVERAGE
FOR 12-MONTH POLICY PERIOD
RATES FOR $100
BUSINESS, PROFESSION
NUMBER OF EMPLOYEES,
INCLUDING PAYROLL OF
OF REMUNERATION
PREMIUM
CONDUCTED IN PA
INCLUDE EXECUTIVE OFFICERS
EXECUTIVE OFFICERS
Rates may be found on our Web site at , Keyword: swif
15. If any employee is estimated to earn less than $10,000 annually, please provide an explanation.
16. Payment Terms
a. All policies less than $2,000 – TOTAL PAYMENT REQUIRED.
b. All policies $2,000 to $10,000 – 25% OF TOTAL PREMIUM, OR MINIMUM PREMIUM, WHICHEVER IS GREATER,
with the remaining balance due in four (4) equal installments.
c. All policies over $10,000 – 25% OF TOTAL PREMIUM, OR MINIMUM PREMIUM, WHICHEVER IS GREATER, with
the remaining balance due in ten (10) equal installments.
Requested inception date of coverage:
NOTE: ALL INCOMPLETE APPLICATIONS OR THOSE WITHOUT THE PROPER REMITTANCE WILL BE RETURNED
WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU SUBMIT.
17. Contract Conditions
a. Coverage will become effective at 12:01 AM on the day specified on the workers' compensation policy issued
by SWIF. Said policy will be issued within 30 days of the submission of a completed application.
In order for an application to be deemed complete and acceptable for review and coverage, the SWIF must
receive a complete and properly signed application and the specified premium due.
SWIF-429 REV 4-08 (Page 3)
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