Pennsylvania > Workers Comp
Section 304.2 Application For Religious Exception Of Specified Employes LIBC-14A - Pennsylvania
| Section 304.2 Application For Religious Exception Of Specified Employes Form. This is a Pennsylvania form and can be used in Workers Comp . |
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UBC-14A REV 1-96 SUBMIT APPLICATION TO: SECTION 304.2 APPLICATION FOR RELIGIOUS EXCEPTION OF SPECIFIED EMPLOYES FROM COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY THE PROVISIONS OF THE PENNSYLVANIA BUREAU OF WORKERS COMPENSATION 1171 S. CAMERON STREET. ROOM 103 WORKERS COMPENSATION ACT HARRISBURG, PA 17104-2501 Name of Employer Address Employer is Sole Proprietor Partnership Corporation Nature of Business of Employer -- - - -- - -- - - (a) Total number of all persons employed by this employer (b) Total number of employes for whom exception is sought Employers Current Workers Compensation Coverage: tf self-insurer, effective date of certificate and Bureau code number If covered by insurance policy: Name of insurance company Name and address of insurance agent, if any - Policy number Policy effective date Full name of religious sect including division thereof Name and address of local leader of above religious sect Does religious sect above provide, financial or otherwise, for injured or deceased members and families thereof? Yes No List employe member(s), address and social security number, requesting exception under the Pennsyl- vania Workers Compensation Act. NOTF: For each employe listed, an executed copy of the "Employ- es Affidavit and Waiver of Workers Compensation Benefits and Statement of Religious Sect" must be attached to this application. (1) Name of Employe S.S. # Address (2) Name of Employe S.S. # Address (3) Name of Employe S.S. # Address (4) Name of Employe S.S. # Address (5) Name of Employe S.S. # Address (6) Name of Employe S.S. # Address NOTE: If additional employes, check here and attach separate list(s). <<<<<<<<<********>>>>>>>>>>>>> 28. List employes requesting who exception have been granted a similar exception from coverage under the Federal Social Security System and attach a copy of the approved Internal Revenue Service Form 4029, if available: (1) Name of Employe (2) Name of Employe (3) Name of Employe (4) Name of Employe (5) Name of Employe (6) Name of Employe This application must be signed by the employer or, if a corporation, an officer thereof as set forth below. EMPLOYER OFFICER AND TITLE TELEPHONE NUMBER
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