AGC Participation Agreement {1018-IE}

Workers Compensation Fund AGC Participation Agreement Provided by Workers Compensation Fund for the members of the Associated General Contractors 1 BUSINESS NAME Give Exact or Full Name Policy Number 2 MAILING ADDRESS Street or P.O. Box City State Zip Code Business Telephone Number Fax Number In order to be eligible for, and continue in the program, I/we agree to adhere to the following: 1. Implement written recommendations made by WCF's safety and health staff pertaining to hazards that would qualify as OSHA serious violations. 2. Report claims within seven days of employer's knowledge and cooperate with WCF's claims staff as required in the workers compensation policy. 3. Attendance by an owner, member of management or supervisor at a minimum of two WCF safety seminars each policy year. These seminars must be conducted by WCF's safety and health staff. Association sponsored seminars may be used to satisfy this requirement only if the course has been pre-approved by WCF's safety and health management and the content is directly related to injury prevention. This requirement may also be satisfied by completion, within the policy year, of an OSHA 10-hour or 30-hour course. A copy of the instructor's OSHA certification must be provided along with the graduation certificate of the student. Association members must meet program eligibility criteria established by WCF and the Associated General Contractors in order to participate in the program. Termination of membership in the Associated General Contractors, failure to comply with participation guidelines, or the expiration or cancellation of workers' compensation coverage through WCF will void this agreement. Should you, for any other reason, elect to terminate this agreement, written notification must be submitted to the Associated General Contractors and Workers Compensation Fund. Print or Type Name and Title of Contact Person Signature of Contact Person Date Please retain a copy for your records and give the original to your agent or marketing representative, or send to: Workers Compensation Fund 100 West Towne Ridge Parkway Sandy, Utah 84070 800.446.2667 | Fax: 385.351.8984 www.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 1018-IE (Rev. 7/13) American LegalNet, Inc. www.FormsWorkFlow.com