West Virginia > Workers Comp
Application For Coverage Under Coal-Workers Pneumoconiosis Fund BI-BL1 - West Virginia
| Application For Coverage Under Coal-Workers Pneumoconiosis Fund Form. This is a West Virginia form and can be used in Workers Comp . |
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BI-BL1 Application for Coverage under Coal-Workers' Pneumoconiosis Fund Return complete form to: BrickStreet Mutual Insurance P.O. Box 3064 Charleston, WV 25332-3064 Telephone: (304) 926-3400 Fax: (304) 926-1996 01/06 BrickStreet use only C.W.# Status Class County Effective Date Wages Rate Remitted The undersigned hereby applies for coverage by the Coal-Workers' Pneumoconiosis Fund of the State of West Virginia of liability created by Title IV of the Federal Coal Mine Health and Safety Act of 1969, as amended, and as provided in Article 4B, Chapter 23 of the West Virginia Code, as amended, and further agrees by making this application to be bound by the rules and regulations of the Coal-Workers' Pneumoconiosis Fund. Failure of the subscriber to timely file quarterly payroll and premium reports and to pay any premium due shall result in action taken by the Fund to cancel the subscriber's insurance coverage. 1. Name 3. Address Street or P.O. Box 4. Type of Business entity: (check one) / / 5. Date licensed to do business in WV (attach verification) City Sole proprietorship Corporation State of incorporation: County Partnership / / State Other: 7. BrickStreet Policy Number Zip Code A . I DE N T I F I C A T I O N O F A P P L I C A N T . 2. Telephone number (include area code) 6. If a corporation: (attach verification) Date of incorporation 8. If a corporation, partnership, or sole proprietor, list names and social security numbers of officers or owners 9. Is the applicant a lessee? Yes No If yes, provide the name and address of the lessor and attach copies of the lease agreements. US E B L A CK IN K. 10. Is the applicant a subsidiary of any other business entity? Yes If yes, provide the name and address of the parent organization. No 11A. Is the applicant a transferee or successor of another business entity? Yes No If yes, provide the name and address of the transferor or predecessor entity (attach copies of all documents and agreements of transfer or succession.) 12. Address at which a field auditor may conduct an audit of your payroll 11B. Has the applicant ever had coverage before? If yes, what was the policy number? Yes No Contact person: Telephone number: B . E MP L O Y E E & P A Y R OL L I N F O R MA T I O N P R E V I O U S T O A P P L I C A T I O N . 1. Date you began coal mine operations / / 2. Estimated average number of employees: For the next three months: For the next year: 4. Total estimated gross payroll for all operations for the next three months: Underground $ 3. Estimated gross payroll: For the next three months: $ For the next year: $ Surface $ C. O PERATIONS INFORMATION MUST BE GIVEN FOR ALL W EST VIRGINIA OPERATIONS . ATTACH ADDITIONAL SHEETS IF MORE SPACE IS NEEDED . 1. Name of operation 4. Type of operation Underground Other (explain) Surface Trucking 2. Location (include county) 5. Federal Employer's Identification Number (FEIN) 3. Federal Mine Identification Number 6. Date operation began or will begin / / CERTIFICATION I certify, swear, or affirm that all of the statements made and information provided within or accompanying this application are true, complete, and correct to the best of my knowledge and belief and are made in good faith. Signature of owner or principal officer (sign in ink) Title Date BrickStreet Mutual Insurance P.O. Box 3064 Charleston, WV 25332-3064 American LegalNet, Inc. www.USCourtForms.com
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