State Workers Insurance Application Page 4
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4b. The application, including any subcontractor information elicited at Item 12 of the application, must be properly
and fully completed and signed by an owner, or partner, or a corporate officer.
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 the State Workers’ Insurance Fund 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 I-9 forms. The determination of proper
premium payments is dependent upon the accuracy of such records. Any failure to provide accurate and
legitimate payroll records, at any time, will be considered a material breach entitling SWIF to either rescind the
contract to insure, refuse to insure, or cancel the policy.
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 by the
underwriting visit or audit will be used to determine the estimated or final premium. If it is determined that
additional premium is due, you will be billed accordingly.
Employees hired in and working in another state cannot be covered by the Pennsylvania State Workers’
f.
Insurance Fund.
VERY IMPORTANT NOTICE
ALL INFORMATION SUPPLIED BY THE APPLICANT IS SUBJECT T
VERIFICATION PURSUANT TO 77 P .S. §2615 AND 77 P .S. §2616.
THE APPLICATION MUST BE SIGNED BY AN OWNER, A PARTNER OR A CORPORATE OFFICER
AND RETURNED WITH YOUR CHECK.
I verify that this information is true and correct based upon my knowledge, information and belief. I understand
that if the information I have provided on the application is false, incomplete or misleading, I may have violated
77 P .S. §1039.2, pertaining to workers’ compensation fraud, and be subject to the penalties set forth at 77 P .S.
§1039.5 and 77 P .S. §1039.6. I also understand that if I have made any false statements on this application, I may
have violated 18 Pa. C.S.A. 4117, pertaining to unsworn falsification to authorities, which is a misdemeanor of the
second degree.
18.
SIGNATURE
TITLE
DATE
Print Name of Signature
19. BROKER OF RECORD LETTER: The following Broker / Agent has been designated as the “official broker of
record” . (The following information must be completed and signed by both the Broker / Agent and the
Insured.) No additional Broker of Record Letter is required.
BROKER/AGENT NAME OR INSURANCE AGENCY NAME
ADDRESS
TELEPHONE NO.
SIGNATURE OF BROKER/AGENT
SIGNATURE OF INSURED
(OWNER, PARTNER, OR CORPORATE OFFICER)
BUSINESS FAX NO.
E-MAIL
20. FISCAL AGENCY AND ADDRESS:
ADDRESS
TELEPHONE NO.
FAX NO.
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
SWIF-429 REV 4-08 (Page 4)
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