Application For Utah Workers Compensation And Utah Liability Insurance {1001-3}

Workers Compensation Fund Application for Utah Workers Compensation and Employers Liability Insurance Please print or type 1 Business Name Give Exact and Full Name Years in Business 2 Mailing Address Street or P.O. Box City E-Mail Address of Workers Compensation Contact State Zip Code Business Telephone No. Fax No. 3 Payroll Record / Location (Payroll Audit) / Check if Same as Mailing Address Street or Location Description City State Zip Code Payroll Telephone No. Name of Person to Contact 4 Nature of Business / Description of Operations 5 Ownership Information Type of Ownership Sole Proprietor Joint Venture Limited Partnership Partnership Limited Liability Co. Government Corporation Association Other Unemployment No. Federal Tax I.D. No. Note: A partnership or sole proprietorship may elect to include as an employee any partner of the partnership or the owner of the sole proprietorship. For premium computation purposes, the salary wage of partners or sole proprietors shall be 100% of the state average weekly wage. A corporation may elect not to include any director or officer of the corporation as an employee. List Below Complete Information for: Sole Proprietor Partners Corporate Officers Name (Last, First, Middle Initial) Title % of Ownership Social Security No. Coverage Desired? (Yes / No) Principle Duties American LegalNet, Inc. www.FormsWorkFlow.com 6 Previous Insurance Coverage? Policy Period from (MO / YR) to (MO / YR) No Yes ( If Yes, please provide information for last three years ) Experience Modifier Claims Cost, Including Reserves Insurance Company Name Annual Premium 7 Names (including DBA's) and Street Addresses of All Utah Locations Name Street or Location (use additional page if necessary) City Zip Code 8 Work Classifications and Estimated Annual Payroll by Location By Location, List Duties of Employees Including Covered Corporate Officers by Type of Work Performed. Do Not Include Earnings of Partners or Sole Proprietor. No. of Employees Estimated Total Annual Payroll Class Codes WCF Use Only Rate Estimated Premium 1 2 3 4 9 Employer's Liability Insurance Employers Liability Insurance provides coverage against lawsuits brought by an Employee against the Employer for on-the-job injuries. Standard limits for the policy are: Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease (Each Accident) (Policy Limit) (Each Employee) $100,000 $500,000 $100,000 WCF Use Only Total Estimated Manual Premium Increased Liability Limits E-Mod Factor Scheduled Credit / Debit Factor Premium Size Discount Estimated Annual Premium If higher limits are desired, please contact the Underwriting Department for available options and costs. WCF Use Only Payment Plan: Agency Name: Underwriter: Agency Code No. Producer Down Payment Effective Date Number Assigned American LegalNet, Inc. www.FormsWorkFlow.com 10 General Questions Questions 1 Does applicant own, operate or lease aircraft / watercraft? 2 Do / have past present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting hazardous material? 3 Any work performed underground or above 15 feet? 4 Is applicant engaged in any other type of business? 5 Are sub-contractors used? If yes, give % of work subcontracted. 6 Any work sublet without certificate of insurance? 7 Is a written safety program in operation? 8 Any group transportation provided? 9 Do employees travel out-of-state? Y N 10 Are athletic teams sponsored? 11 Any prior coverage declined, cancelled, or non-renewed within the last 3 years? 12 Are employee health plans provided? 13 Is there a labor interchange with any other business / subsidiary? 14 Do you lease employees to or from other employers? 15 Do any employees predominantly work at home? 16 Any tax liens or bankruptcy within the last 5 years? 17 Any undisputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises? If yes, explain including entity name(s) and policy number(s). Y N 11 Remarks 12 Individual to Contact if Additional Information is Needed Name Telephone Number It is agreed that contractors and sub-contractors engaged by the applicant who cannot provide a Certificate of Workers Compensation Insurance substantiating an active workers compensation policy shall be included in the applicant's payroll and premium paid by the applicant. Upon receipt of the completed and signed application, Workers Compensation Fund will provide the applicant with a proposal showing the classifications, rates and deposit required. In order to initiate coverage, applicant must return one copy of the proposal with the required payment to Workers Compensation Fund. Coverage will be effective at 12:01 am on the date following receipt of one copy of the signed proposal and required payment by Workers Compensation Fund. Print or Type Name and Title of Owner, Partner or Corporate Officer Signature of Owner, Partner or Corporate Officer Date Please return a completed signed application to: Workers Compensation Fund P.O. Box 2227 Sandy, Utah 84091-2227 If you have any questions, please call 385.351.8156 Fax: 385.351.8984 Email: applications@wcfgroup.com 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. WCF 1001-3 (Rev. 1/12) American LegalNet, Inc. www.FormsWorkFlow.com