Application For Executive Officer'S Declaration

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application for executive
officer’s declaration
bureau of workers’ compensation
INSTRUCTIONS: If not filing electronically, submit one original application for the corporation along with an Executive
Officer’s Declaration for every officer having an ownership interest. The total ownership interest of all declarations combined
must equal 100 percent. If the corporation has workers’ compensation insurance, all forms must be submitted directly to the
insurance carrier. If not, submit all original forms to: Bureau of Workers’ compensation, compliance section, 1171
south cameron street, Harrisburg, pa 17104-2597
corporation inforMation
Federal employer identification number
Telephone
-
-
-
Corporation’s full legal name
Corporation address
Corporation address
City/Town
State
ZIP
-
Does the corporation have Pennsylvania employees other than those listed on the attached declarations(s)?
Yes
No
If yes, employer’s current workers’ compensation coverage:
Insurance company name
Policy number
-
-
Policy effective start date
Policy effective end date
-
-
MM
DD
YYYY
MM
DD
YYYY
Corporation type:
(check only one box)
Subchapter S
Subchapter C
Nonprofit
I, the undersigned, verify that I am signing in my capacity as an Executive Officer for the above named corporation and
that I am authorized to do so. I further verify that the facts set forth in this Executive Officer’s Exception Application are
true and correct to the best of my knowledge, information and belief. This verification is made subject to the penalties of
18 Pa.C.S. §4904, relating to unsworn falsification to authorities.
-
-
Signature of Executive Officer
Date
MM
DD
YYYY
First name
Last name
Title
NOTE: If not filing electronically, send the original to: Bureau of Workers’ Compensation, Compliance Section,
1171 south cameron street, Harrisburg, pa 17104-2597
Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of Section 1102 of the Pennsylvania Workers’ Compensation Act,
77 P.S. §1039.2, and may also be subject to criminal and civil penalties under 18 Pa. C.S.A. §4117 (relating to insurance fraud).
employer information
claims information services
Hearing impaired
email
services
toll-free inside PA: 800.482.2383
toll-free inside PA TTY: 800.362.4228
ra-li-bwc-helpline@pa.gov
717.772.3702
local & outside PA: 717.772.4447
local & outside PA TTY: 717.772.4991
*509*
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LIBC-509 REV 09-13

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