Form Sfn 5556 - Application For Insurance (Page 2 of 2) in pdf

APPLICATION FOR INSURANCE (con’t)

PAGE 2 OF 2

NDWC MUST BE NOTIFIED IMMEDIATELY OF ANY CHANGES IN OPERATIONS, OWNERSHIP, PARTNERS, OR CORPORATE OFFICERS:

EMPLOYER(S) COVERAGE: Coverage for the owner, partner, or corporate officers of a business corporation is optional. List the names of these

individuals(s) if optional coverage is desired. An employer electing optional coverage will be charged an annual premium based upon the maximum taxable

payroll cap. Coverage becomes effective upon NDWC’s receipt of a completed, signed optional coverage contract.

NAME

TITLE

SOC. SEC. NO.

% OWNED

IS COVERAGE DESIRED?

Yes

EMPLOYER’S SPOUSE AND/OR CHILDREN: You must list the spouse, and all children under the age of 22 of the employer(s) who have received or will

receive compensation from your business. COVERAGE FOR SPOUSE AND CHILDREN UNDER AGE 22 IS PROVIDED BY SPECIAL CONTRACT ONLY.

Spouse – Premium calculated on wage cap amount. Children 17 and under for payroll period – Premium based on actual wages. Children 18 to 21 for payroll

period – Premium calculated on wage cap amount. Children 22 and older for payroll period – Actual wages would be reported along with the other

employees. Coverage becomes effective upon NDWC’s receipt of a completed, signed optional coverage contract.

NAME OF

SOCIAL

DATE OF

CLASS

ACTUAL

ESTIMATED

IS COVERAGE

RELATIONSHIP

FAMILY MEMBER

SECURITY NO.

BIRTH

CODE

WAGES

DESIRED?

Yes

COMPLETE IF YOU ARE AN OUT-OF-STATE CORPORATION OR OUT-OF-STATE COOPERATIVE ASSOCIATION:

State of Incorporation

Date of Incorporation (MM/DD/YYYY)

ESTIMATED PAYROLL FOR NEXT 12-MONTH PERIOD: (additional sheets may be attached)

Describe all types of work performed within the business (e.g., clerical office, janitorial, traveling personnel, shop workers, etc.) Give

number of employees engaged in that type of work and estimate the payroll which will be expended for each in the next 12 months.

NUMBER OF

SHADED AREA FOR NDWC USE ONLY

ESTIMATED PAYROLL

PLACE WHERE WORK IS

DESCRIPTION OF WORK

EMPLOYEES

(INCLUDE ROOM AND

CLASSIFICATION

EMPLOYEE

PERFORMED

(not including

BOARD ALLOWANCE)

CODE

PAYROLL

owners)

Do your North Dakota based employees work in states other than North Dakota?

Yes

North Dakota Workers Compensation has reciprocity agreements with the following seven states. These agreements allow North Dakota

Workers Compensation to cover North Dakota based employees while they temporarily work in these states. We will file for reciprocal

coverage in each of the states you request below.

If your employees are working in any states other than those listed, you should contact those states to ensure compliance with their state

laws. Restrictions may apply in certain states.

COMPLETE IF YOU ACQUIRED THE BUSINESS IN WHOLE OR IN PART:

Date of Acquisition (MM/DD/YYYY)

Prior Owner’s Business Name

Address

Account Number (if known)

Does any owner, partner, or corporate officer currently have, or have they previously had, an account with NDWC?

Yes

If yes, please list under what name and account number:

IF RECORDS ARE MAINTAINED BY OUTSIDE ACCOUNTANT:

Outside Accountant Name

Outside Accountant Phone

Outside Accountant E-mail Address

THE APPLICATION MUST BE SIGNED.

IF SOLE PROPRIETORSHIP, BY OWNER; IF A HUSBAND/WIFE OWNERSHIP, BY BOTH HUSBAND AND WIFE; IF A PARTNERSHIP,

BY EACH PARTNER (ADDITIONAL SHEETS MAY BE ATTACHED). IF A CORPORATION OR ASSOCIATION, THIS APPLICATION

MUST BE SIGNED BY THE OFFICERS(S) HAVING CONTROL, OR SUPERVISION OF, OR CHARGED WITH THE RESPONSIBILITY

FOR FILING PAYROLL REPORTS AND MAKING PAYMENTS, OR AUTHORIZED REPRESENTATIVE.

Signature

Printed Name

Title

Date

Signature

Printed Name

Title

Date

Form Sfn 5556 - Application For Insurance Page 2

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