Form Swif-51 - Voluntary Election Of Coverage Form - Labor & Industry (Page 2 of 2) in pdf

Form Swif-51 - Voluntary Election Of Coverage Form - Labor & Industry Page 2

NOTE: Your Voluntary Election of Coverage, by law, applies to all entities combined in

coverage under this policy.

SOLE PROPRIETOR ELECTING COVERAGE: I, the below named sole proprietor, do hereby

knowingly and voluntarily elect to be an employee of the below named business for purposes of the

Pennsylvania Workers’ Compensation Act.

MEMBER OF AN LLC ELECTING COVERAGE: I, the below named member, do hereby knowingly

and voluntarily elect to be an employee of the below named business for purposes of the

Pennsylvania Workers’ Compensation Act.

PARTNER OF A PARTNERSHIP ELECTING COVERAGE: I, the below named partner, do hereby

knowingly and voluntarily elect to be an employee of the below named business for purposes of the

Pennsylvania Workers’ Compensation Act.

Job description of owner

Social Security number

Email address

Business’s full legal name

Address

Phone

City, state, ZIP

Wages

FEIN

Policy/quote number:

Policy/quote effective date:

Electing coverage at this time

Declining coverage at this time

I verify that the facts set forth in this Election of Coverage 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 owner

Percentage of ownership

Print name

Date

Department of Labor & Industry | State Workers’ Insurance Fund | 100 Lackawanna Avenue

P.O. Box 5100 | Scranton, PA 18505-5100 | 570-963-4635 |

Auxiliary aids and services are available upon request to individuals with disabilities.

Equal Opportunity Employer/Program

SWIF-51 REV 01-17 (Page 2)

Form Swif-51 - Voluntary Election Of Coverage Form - Labor & Industry Page 2