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Voluntary Election Of Coverage

STATE WORKERS’ INSURANCE FUND

VOLUNTARY ELECTION OF COVERAGE

Sole Proprietors, Partners of a Partnership or Members of an LLC electing to be covered under the Pennsylvania

Workers’ Compensation Act must complete this Election of Coverage Form. Premium will be based on total

payroll, subject to the same minimum and maximum payroll as an executive officer, $20,800 (minimum) to

$109,200 (maximum) per year. This will be subject to review at audit time by copies of the net self employment

earnings form for a sole proprietor, corporate tax return for LLCs and Form 1065 for partners. The minimum

payroll figure is the smallest payroll amount SWIF can use for the policy but the policy will be based on actual

payroll should the actual payroll be higher than $20,800.

In the event a claim is submitted under Sections 306 or 307 of the Pennsylvania Workers’ Compensation Act, the

payroll reported at the time of application or during a subsequent audit will be considered as part of the Average

Weekly Wage calculation.

All Voluntary Elections of Coverage will be in effect for the full policy period and will remain in effect for

each policy renewal until the State Workers’ Insurance Fund is provided written notification to the contrary. You

must select one of the business types below that describes your business entity. Do not make a selection if you

are declining coverage. Each Partner and or Member must complete one of these forms. Coverage will not be

added or deleted during the policy term.

BE ADVISED THIS FORM IS NOT FOR EMPLOYEES AND, IF COMPLETED BY THE OWNER,

CANNOT BE VOIDED UNTIL THE FOLLOWING RENEWAL

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.

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.

I, the below named Member of an LLC, do hereby knowingly and voluntarily elect to be an

employee of the below named business for purposes of the Pennsylvania Workers’

Compensation Act.

Voluntary Election Of Coverage