Voluntary Election Of Coverage Page 2

NOTE: Your Voluntary Election of Coverage, by Law, applies to all businesses covered under

this policy

Job Description of Owner to be Included

Social Security Number

Business’s Full Legal Name

Address

________________________________________________Phone ________________________________________

City, State, Zip

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

Payroll

Date_________

Print Name of Signature

Revision-2011

SWIF- POL115

Department of Labor & Industry | State Workers’ Insurance Fund | 100 Lackawanna Avenue, P.O. Box 5100 |

Scranton, PA 18505-5100 | Ph 570.963.4635 |

Equal Opportunity Employerogram

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