Get State Workers Insurance Fund

Navigating the State Workers Insurance Fund form can seem daunting, but with clear guidance, you can complete it efficiently. This document assists sole proprietors, partners, and LLC members in electing coverage under Pennsylvania Workers’ Compensation Act.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the provided editor.
2. Indicate your business type by selecting from the options provided if you are opting for coverage. If you are choosing not to take coverage, leave this section blank.
3. In the section ‘Job Description of Owner’, provide a clear and concise description of your job responsibilities within the business.
4. Fill in your 'Social Security Number', ensuring that it is accurate.
5. Enter your 'Email Address' for official correspondence regarding your coverage.
6. Complete the 'Business’s Full Legal Name' with the official registered name of your business entity.
7. Provide your business’s address, including street, city, state, and zip code.
8. List a contact 'Phone' number where you can be reached for any inquiries.
9. Complete the section for 'Wages', citing your intended wages in accordance with required guidelines.
10. Fill out your 'FEIN' (Federal Employer Identification Number) for tax purposes.
11. Write your 'Policy/Quote Number' and check the effective date for the policy or quote you are applying under.
12. Select between 'Electing Coverage at this time' or 'Declining Coverage at this time' based on your choice.
13. Finish the form by signing it to verify that all provided information is true and accurate, and include your 'Percentage of Ownership' and 'Date' of signing.
14. Once all fields are completed, save your changes, and choose to download, print, or share the form as needed.

Complete the State Workers Insurance Fund form online today to ensure your coverage is established correctly.