Fillable APPLICATION FOR WORKERS COMPENSATION INSURANCE COVERAGE - R (Pennsylvania)

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APPLICATION FOR WORKERS COMPENSATION INSURANCE COVERAGE - R (Pennsylvania)

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APPLICATION FOR
WORKERS’ COMPENSATION
DEPARTMENT OF LABOR & INDUSTRY
STATE WORKERS’ INSURANCE FUND
INSURANCE COVERAGE - R
Dear Employer: Thank you for doing business in Pennsylvania! Please ll out this application
accurately and completely. Doing so will help us process your application as quickly as possible.
• It is mandatory that employers carry workers’ compensation insurance per the Pennsylvania Workers’
Compensation and Occupational Disease Acts.
• Failure to comply with these laws subject employers to lawsuits by employees and criminal prosecution
could result in substantial nes, imprisonment, or both.
• The carrier must have an insurable interest to write a workers’ compensation policy; having no
employees constitutes no insurable interest. State Workers’ Insurance Fund (SWIF) is prohibited
from issuing a policy on an “if any” basis.
COMPLETE AND SIGN THE APPLICATION
Please complete and submit this application by mail to: State Workers’ Insurance Fund,
100 Lackawanna Ave, PO Box 5100, Scranton, PA 18505-5100.
Payment: Checks (black or blue ink only) and money orders should be payable to “SWIF.” Providing a check
as payment authorizes SWIF to either make a one-time electronic fund transfer (EFT) from your account or
to process the payment as a check transaction. Cash payments are not accepted.
For policies less than $2,000 in premium, total payment is required. For policies $2,000 or greater in
premium, SWIF requires a payment of 25 percent of the premium OR the minimum premium, whichever is
greater, including the Employer’s Assessment Fee, Terrorism Fee, and Commercial Catastrophe Fee. Under
certain circumstances, at SWIF’s discretion, the total premium may be required before coverage will be
incepted. See 15. Payment Terms on page 6. For more information, visit www.dli.pa.gov/swif select
“Underwriting,” then select “How to Obtain a Policy.”
Additional Information and Assistance: Should you have any questions about the application or coverage,
please contact Customer Service at 570-963-4635.
• SWIF does not oer waiver of subrogation endorsements.
• If you are a sole proprietor, partners of a partnership, or members of an LLC, complete the Voluntary
Election of Coverage form (SWIF-51) indicating your choice to accept or decline coverage.
• If you are a corporate ocer and/or owner choosing to waive your rights, complete and submit the
Application for Executive Ocer Exception (LIBC-509) & Executive Ocer’s Declaration (LIBC-513) forms.
• All required forms and resources may be found either on the SWIF website www.dli.pa.gov/swif or
as specied in this application.
Any party who willfully makes a false statement or representation, deliberately conceals any material fact,
or engages in any other fraudulent scheme or device, for the purpose of obtaining or attempting to obtain,
or for the purpose of aiding or abetting any person to obtain insurance in the SWIF at less than the proper
rate for such insurance, or payment out of SWIF to which such person is not entitled, is guilty of a crime.
Providing false information on this application or engaging in fraud can lead to the applicant being disbarred
from being awarded a contract with the commonwealth for as long as three years and may further lead to
disbarment with local governments in the commonwealth.
I UNDERSTAND AND WILL COMPLY WITH THE INFORMATION ON THIS PAGE
BUSINESS NAME:
SIGNATURE: (Owner/Corporate Ocer/Partner) Date:
NOTE: Signatures on page one and page seven should match.
SWIF-429R 12-19 (Page 1)
FOR OFFICE USE ONLY: Application # Check # Amount $
PLEASE COMPLETE THE FOLLOWING APPLICATION FOR WORKERS’ COMPENSATION INSURANCE
1. a. Business Name:
b. Mailing Address: City: State: Zip:
c. PA Primary Operating Location: County:
d. Telephone: Business Fax:
e. Email: f. Website:
2. Federal Employer Identification Number: (active FEIN is required;
www.irs.gov to apply)
a. If new, date applied:
b.
List the name and FEIN of each additional business owned and operated to be included in this policy:
c. If multiple entities are to be insured on one policy, submit a Condential Request for Information
(ERM-14) form to identify each business.
d. Has any principle applicant had a previous business that was insured by SWIF under a dierent
name, entity, or FEIN? If yes, include names of previous business(es), names of owners/ocers of
the business(es), and FEIN(s):
3. PLEASE USE THE FOLLOWING GUIDE TO DETERMINE WHETHER YOU MUST COMPLETE
TABLE A (3a) OR TABLE B (3b) ACCORDING TO YOUR TYPE OF ENTITY:
THIS SECTION NEEDS TO BE COMPLETED IN FULL OR YOUR APPLICATION WILL BE RETURNED WITH NO COVERAGE.
Indicate the type of business (check all that apply):
 Individual/Sole Proprietor
 Partnership
 Limited Liability Company
 Limited Liability Partnership
 Corporation (S or C)
 Non-Prot Corporation
 Professional Employer Organization
 Temporary Agency
 Other (Please specify, i.e. PEO client)
Complete Table A – Sole proprietors,
partners of a partnership or LLP, members of
an LLC electing or declining to be included
under the Act must complete a Voluntary
Election of Coverage (SWIF-51) form.
Complete Table B – An executive ocer of a
corporation, if eligible, may elect to be
exempt under the Act by completing and
submitting an Application for Executive Ocer
Exception (LIBC-509) & an Executive Ocer’s
Declaration (LIBC-513). If not submitted,
owners/ocers will remain included for the
entire policy term.
NOTE: ALL INCOMPLETE APPLICATIONS OR THOSE WITHOUT THE PROPER REMITTANCE WILL BE RETURNED
WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU SEND.
SWIF-429R 12-19 (Page 2)
Clear All Fields
3a. TABLE A: Has this business entity been insured with SWIF before? Yes  No 
Ownership for the Sole Proprietor / Partner / LLP / LLC – List each owner separately
First and Last Name
Sole Proprietor /
Partner Member
SS#
%
Ownership
Class
Code
Active
Y/N
Covered
Y/N
3b. TABLE B: Has this business entity been insured with SWIF before? Yes  No 
Ownership/Title for: S or C Corporation / Non-Prot – List each owner separately
First and Last Name Corporate Ocer Title SS#
%
Ownership
Class
Code
Active
Y/N
Covered
Y/N
i. Date articles led: ii. State:
4. Is this business currently in the process of liquidation or termination?
 No
 Yes – explain:
5a. Has this business ever led for bankruptcy?
 No
 Yes – date led:
5b. Is this business currently in bankruptcy?
 No
 Yes – Must enclose a copy of the petition as led in bankruptcy court, including all attachments.
6. Audit Contact
Contact Person:
Address: City: State: Zip:
Telephone: Email:
NOTE: ALL INCOMPLETE APPLICATIONS OR THOSE WITHOUT THE PROPER REMITTANCE WILL BE RETURNED
WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU SEND.
SWIF-429R 12-19 (Page 3)
7. Safety/Loss Control
Contact Person:
Address: City: State: Zip:
Telephone: Email:
8. Has this business entity had previous workers’ compensation insurance coverage in Pennsylvania?
No
Yes – answer the following completely:
a. Business Name:
b. Carrier Name:
c. Policy Number:
d. Date Cancelled/Expired:
e. Anniversary Date:
f. Premium:
g. Carrier information for the previous three (3) years:
Carrier Premium Year
Carrier Premium Year
Carrier Premium Year
PLEASE NOTE: IF YOUR PREMIUM IS IN EXCESS OF $20,000, ATTACH FIVE YEARS OF
DETAILED LOSS AND PREMIUM HISTORY.
h. Pennsylvania Compensation Rating Bureau #:
i. Experience Modication/Merit: Date:
j. Home Improvement Contractor Number (HIC#):
9. Has workers’ compensation coverage ever been cancelled for this business entity?
No
Yes – explain:
10. a. Provide a COMPLETE AND DETAILED job description of all work performed by classication of
your day-to-day operations, including the job duties of the corporate ocers and/or owners.
(Attach an additional sheet, if necessary.)
NOTE: ALL INCOMPLETE APPLICATIONS OR THOSE WITHOUT THE PROPER REMITTANCE WILL BE RETURNED
WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU SEND.
SWIF-429R 12-19 (Page 4)
Provide the following where applicable on a separate page:
b. List of clerical employees and their job duties
c.
Volunteer Fire Department Roster (Act 46) and Volunteer Fireman Exposure form at www.pcrb.com
d. List of the names and social security numbers for any domestic workers. Include number of hours
worked per week per employee (part time – under 20 hours; full time – 20 hours or more).
e. Approval to Exempt Certain Religious Members (LIBC-14C) form at www.wcais.pa.gov
f. Letter of Certication Approval of Workplace Safety Committee from the Bureau of Workers’
Compensation (Safety Credit)
11. Does this business entity engage or use any of the following:
Privately-owned or leased aircraft
Maritime/harbor workers (NOTE: SWIF does not oer Jones Act coverage)
U.S. Department of Defense contracts, outside U.S. Territories
N/A
12. Does this business utilize the services of subcontractors, owner-operators, and/or independent
contractors in the operation of your business?
 No
 Yes – Please provide the following:
• A copy of Certicates of Insurance (COI) for all subcontractors proving workers’
compensation coverage in Pennsylvania.
• A copy of the signed contracts between the applicant and the subcontractor(s) as
required per Act 72.
If valid COIs cannot be provided, please submit a completed Independent Contractor Questionnaire
form (SWIF-831). Owner-operators must complete the Trucking Questionnaire form (SWIF-832). Any
subcontractors that do not carry workers’ compensation may be included in coverage upon review. Also,
note that SWIF reserves the right to make a determination on the employment status of these individuals
and may require them to be included as employees for workers’ compensation purposes.
Liability limits are set to state minimum ($100K/$100K/$500K);
FOR INCREASED LIMITS:  $500K/$500K/$500K $1million/$1million/$1million
• Employers’ liability insurance provides coverage to employers for liability arising out of a worker’s
injury that is not covered by standard workers’ compensation coverage. This can include liability
to employees, their families, and other associated third parties.
• Standard employers’ liability limits are $100,000 per occurrence for bodily injury, $100,000 per
employee for bodily injury by disease, and $500,000 aggregate for bodily injury by disease.
• These limits can be increased by endorsement and payment of an additional premium. The two
other options for increased limits are $500,000 and $1,000,000, as shown above.
NOTE: ALL INCOMPLETE APPLICATIONS OR THOSE WITHOUT THE PROPER REMITTANCE WILL BE RETURNED
WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU SEND.
SWIF-429R 12-19 (Page 5)
13. Payroll: Additional information such as rates, class codes, and instructions to estimate your premium
may be found on our website: www.dli.pa.gov/swif
NOTE: Payroll for ocers/owners choosing exemption in question #3 should be excluded.
Class Code or
Description
Number of
Employees per Class
Estimated Payroll for
One Year Term
Class Rate per $100
Payroll
Estimated Premium
14. PLEASE REVIEW TO DETERMINE IF ADDITIONAL INFORMATION IS REQUIRED:
a. If this business entity uses temporary workers provided through stang agencies, include
Certicates of Insurance from each agency used.
b. If this business entity contracts with a Professional Employer Organization (PEO) for leased
workers, please provide a copy of signed contracts and/or agreements from each client as well as a
list of employees per contract.
c. If this business entity is a Professional Employer Organization (PEO), please include the
requirements which can be found at requirements www.dli.pa.gov/swif.
d. If this business entity is a temporary agency, complete and sign the Alternate Employer
Endorsement Worksheet which is located at www.dli.pa.gov/swif, select “Underwriting,” then
select “How to Obtain a Policy.” SWIF must be notied of all Alternate Employers (temporary
clients) immediately upon acquisition during the policy term. If any Alternate Employer is
acquired during the policy term without notication to SWIF, claims attributed to those specic
clients will be denied.
* Note: SWIF only provides policy information to the policyholder; that is, only the insured and/or the
authorized agent may request the above information. This includes requesting Certicates of Insurance.
SWIF does not take requests from third parties.
15. Payment Terms:
Policy premiums less than $2,000 TOTAL PREMIUM REQUIRED
Policy premiums $2,000 to $10,000 25% of the total premium, or the minimum premium,
whichever is greater; * with the remaining balance due
in four equal installments.
Policy premiums over $10,000 25% of the total premium, or the minimum premium,
whichever is greater; * with the remaining balance due
in 10 equal installments.
* Total premium includes the Employer’s Assessment Fee, Terrorism Fee, and Commercial Catastrophe Fee.
Requested inception date of coverage:
PLEASE REVIEW FOR COMPLETENESS PRIOR TO SUBMISSION.
NOTE: ALL INCOMPLETE APPLICATIONS OR THOSE WITHOUT THE PROPER REMITTANCE WILL BE RETURNED
WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU SEND.
SWIF-429R 12-19 (Page 6)
16. CONTRACT CONDITIONS:
a. Coverage will become eective at 12:01 a.m. on the day specied on the workers’ compensation
policy issued by SWIF. For an application to be deemed acceptable for review and coverage, SWIF
must receive a complete and properly signed application and the specied premium due.
b. The application, including any subcontractor information elicited in Item 12 of the application,
must be properly and fully completed and signed by an owner, a partner, or corporate ocer.
The Construction Workplace Misclassication Act (Act 72) further established a denition of an
“Independent Contractor” for purposes of Workers’ Compensation as of February 10, 2011, and
information regarding such can be found at www.dli.pa.gov/swif.
c. The premium quoted is based upon the nature of the operations and the estimated payroll disclosed
by the employer in this application. The employer shall furnish SWIF with proper notice of any
changes in the nature of its operations or its estimated payroll; such changes may result in an
increase or decrease in the premium due under this policy. The employer agrees to keep an accurate
record of employees and payroll expenditures, and to report injuries and occupational diseases to
SWIF immediately.
d. SWIF requires the disclosure of accurate and legitimate payroll records. Such payroll records must
include, but are not limited to, a list of each employee’s Social Security number or I-9 forms. The
determination of proper premium payments is dependent upon the accuracy of such records. Any
failure to provide accurate and legitimate payroll records, at any time, will be considered a material
breach entitling SWIF to either rescind the contract to insure, refuse to insure, or cancel the policy.
e. SWIF may conduct underwriting visits and/or audits during regular business hours during the policy
period and within three years after the policy ends. Information developed by the underwriting visit
or audit will be used to determine the estimated or nal premium. If it is determined that additional
premium is due, you will be billed accordingly.
f. When any claim for a temporary worker occurs at a client/Alternate Employer’s location of which
SWIF has not been previously notied, the claim will be denied.
g. Employees hired in and working in another state cannot be covered by the Pennsylvania State
Workers’ Insurance Fund.
SIGNATURES AND CERTIFICATIONS:
THE APPLICATION MUST BE SIGNED BY AN OWNER, A PARTNER, OR A CORPORATE OFFICER
AND RETURNED WITH YOUR PAYMENT.
I certify that all information provided in this document is correct and complete. I acknowledge that
false statements in this document are punishable pursuant to 18 Pa. C.S. §4904 (relating to Unsworn
Falsication to Authorities), 18 Pa. C.S. §4117 (relating to Insurance Fraud) and 77 P.S. § 1039.2
(relating to the Workers’ Compensation Act). A person who knowingly makes a false statement or
knowingly withholds information may be subject to a ne, imprisonment and restitution.
SIGNATURE: DATE:
Print Full Name:
17.
NOTE: ALL INCOMPLETE APPLICATIONS OR THOSE WITHOUT THE PROPER REMITTANCE WILL BE RETURNED
WITHOUT COVERAGE IN FORCE. PLEASE REVIEW FOR COMPLETENESS BEFORE YOU SEND.
SWIF-429R 12-19 (Page 7)
18. BROKER OF RECORD LETTER: The following broker /agent has been designated as the ocial
“Broker of Record.” The following information must be completed and signed by BOTH the broker/
agent and the applicant. No additional Broker of Record Letter is required.
** NOTE: Brokerages are NOT authorized to issue Certicates of Insurance on behalf of the
SWIF. All COIs must be issued by request through SWIF only.
DO NOT ISSUE CERTIFICATES ON BEHALF OF SWIF ON ACORD FORMS OR ANY OTHER
DOCUMENT.
a. BROKER/AGENT NAME OR INSURANCE AGENCY:
b. Name:
c. Address:
d. Telephone: Fax:
City:
e. Email:
State: Zip:
f. SIGNATURE OF APPLICANT:
g. SIGNATURE OF BROKER:
h. Print Name:
Title:
Date:
19. FINANCE COMPANY LETTER: The following nance company has been designated as the ocial
“Finance Company.” The following must be completed and signed by the nance company and the
Insured.
ATTACH COMPLETED AND SIGNED FINANCE AGREEMENT
a. NAME OF FINANCE COMPANY:
b. Name:
c. Address:
d. Telephone: Fax:
City:
e. Email:
State: Zip:
f. SIGNATURE OF COMPANY REPRESENTATIVE:
g. SIGNATURE OF APPLICANT:
h. Print Name:
Title:
Date:
STATE WORKERS’ INSURANCE FUND
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
SWIF-429R 12-19 (Page 8)
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APPLICATION FOR WORKERS COMPENSATION INSURANCE COVERAGE - R (Pennsylvania)

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Completed 27 August 2021

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