Utah > Workers Compensation
Application For Utah Statutory Employee Exlcusion Policy 1001-3A - Utah
| Application For Utah Statutory Employee Exlcusion Policy Form. This is a Utah form and can be used in Workers Compensation . |
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Workers Compensation Fund Application for Utah Statutory Employee Exclusion Policy 392 E. 6400 S. Salt Lake City, UT 84107 Underwriting Phone No. 801-288-8020 PLEASE PRINT OR TYPE 1. BUSINESS NAME GIVE EXACT AND FULL NAME YEARS IN BUSINESS 2. MAILING ADDRESS STREET OR P.O. BOX CITY STATE ZIP CODE BUSINESS TELEPHONE NO. FAX NO. 3. NAMES (INCLUDING DBAs AND ADDRESSES OF ALL UTAH LOCATIONS) NAME STREET OR LOCATION CITY ZIP CODE 4. OWNERSHIP INFORMATION 1. 2. SOLE PROPRIETOR PARTNERSHIP 3. 4. CORPORATION LIMITED LIABILITY CO. 5. LIMITED PARTNERSHIP TYPE OF OWNERSHIP LIST BELOW COMPLETE INFORMATION FOR: NAME (LAST, FIRST, MIDDLE INITIAL) TITLE *Federal ID No. ________________ % OF OWNERSHIP SOCIAL SECURITY NO. 5. NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS 6. PREVIOUS INSURANCE COVERAGE WITH WCF? (IF YES, PROVIDE INFORMATION BELOW) BUSINESS NAME YES NO POLICY # 7. MAKE CHECK IN THE AMOUNT OF $50.00 PAYABLE TO WORKERS COMPENSATION FUND. (THERE WILL BE A $20 SERVICE CHARGE ON ALL RETURNED ITEMS) Name: _____________________________________ [ ] Check is enclosed or [ ] Please charge $50.00 to my: Visa [ ] Mastercard [ ] Discover [ ] Amex [ ] Address: ____________________________________ Account No. ___________________________________ Exp. Date: _______ Telephone: ___________________________________ Authorized Signature: ___________________________ WCF 1001-3A (REV05-05) COMPLETE REVERSE SIDE American LegalNet, Inc. www.FormsWorkflow.com UTAH STATUTORY EMPLOYEE EXCLUSION ENDORSEMENT This endorsement applies only to the insurance provided by the policy because Utah is shown in Item 3.A. of the Information Page. Part One (Workers Compensation Insurance), Part Two (Employers Liability Insurance), Part Three (Other States Insurance) and Part Four (Your Duties If Injury Occurs) of the policy do not apply to the insurance provided by the policy. The policy provides no insurance and no cost is included for the assumption of risk. A premium will be charged to administer and service the policy. The policy is issued in accordance with the provisions of Utah law that authorize exceptions to the application of the statutory employer and statutory employee laws. A copy of this endorsement along with a copy of the Information Page showing this endorsement number in Item 3.D. will serve as evidence of a policy pursuant to §§ 34A-2-103 (7)(c)(ii) and 34A-2-103(7)(e)(ii) of the Utah Code. The insured named in Item 1 of the Information Page certifies that it is a partnership, corporation or sole proprietorship customarily engaged in an independently established trade, occupation, profession or business with no employees other than the partners, corporate officer or officers, or owner. As of the effective date of the policy, I, a partner, corporate officer or owner of the insured named in Item 1 of the Information Page, personally waive my entitlement to the benefits provided by the Utah Workers' Compensation Act and the Utah Occupational Disease Act in the operation of the partnership, corporation or sole proprietorship and in the operation of the partnership's, corporation's or sole proprietorship's enterprise under a contract of hire for services. Signature of Partner, Corporate Officer or Owner Printed Name Date Signature of Partner, Corporate Officer or Owner Printed Name Date Signature of Partner, Corporate Officer or Owner Printed Name Date Signature of Partner, Corporate Officer or Owner Printed Name Date For your protection, Utah law requires the following to appear on this form: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in the state prison. This endorsement must be signed by each partner or corporate officer or owner who is waiving his or her entitlement to benefits. Attach additional copies of the endorsement if additional signatures are required. WC 43 03 01 © 1996 National Council on Compensation Insurance Inc. American LegalNet, Inc. www.FormsWorkflow.com
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