1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Toll Free Fax 1-888-786-8695 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com ALL STATES INCIDENTAL & TEMPORARY OPTIONAL COVERAGE APPLICATION EMPLOYER SERVICES / PHS DIVISION SFN 54163 (11/2008) Business Name WSI Account Number Federal Employer Tax I.D. Number Contact Phone Number State Applicant Name/Title Zip Mailing Address City I request Workforce Safety & Insurance (WSI) to provide “All States’ Incidental & Temporary” insurance protection against injury in the course of employment for my employees. As the employer, I understand that pursuant to N.D.C.C. § 65-04-19.3, this element of workers’ compensation coverage is optional. Once accepted, this insurance provides coverage for incidental and temporary exposures in all states except Ohio, Washington, and Wyoming. I understand this coverage is not a replacement for, or in lieu of, my mandatory workers’ compensation coverage for exposure within the State of North Dakota. Incidental and temporary out-of-state exposures are those exposures defined as out-of-state business operations of an employer for thirty (30) consecutive days or less in a state in which the employer has no contacts sufficient under the workers’ compensation laws of that other state to subject the employer to liability for payment of workers’ compensation premium in that other state. The term of this contract is from the date of receipt by WSI until the employer account renewal date. For those employers who renew in seven months or less, the first year premium shall be $300. For renewal dates greater than seven months, the first year premium shall be $600. Thereafter, this contract is renewed automatically on the renewal date of the employers’ account and payment of the annual $600 premium. No claim for injury under this agreement made during the contract period will be honored if the premium has not been paid by the first premium due date. This contract remains in force until terminated by either party by written notice to the other party, or by written notice to WSI of termination of the employer’s business. WSI may terminate this contract and cancel coverage if: • WSI notifies the employer of its intent to decline renewal of this contract. • WSI discovers the information supplied by the applicant is incomplete, misleading, or fraudulent. P3 American LegalNet, Inc. www.FormsWorkFlow.com ALL STATES’ INCIDENTAL & TEMPORARY OPTIONAL COVERAGE Page 2 of 2 WSI may terminate this contract and cancel coverage if: • The employer’s WSI account is not in good standing. “Not in good standing” is defined as failure to make the minimum payment due by the first due date. • WSI may cancel this policy as of the effective date of coverage. I certify that I have read and understand the provisions of this contract. I understand this is not in force until the effective date of coverage. Employer Authorized Signature Date (or) I certify that I am an approved agent for the above named insured/business. I further certify that I have read and understand the provisions of this contract. Authorized Agent Date For WSI Use Only Effective Date of Coverage P3 American LegalNet, Inc. www.FormsWorkFlow.com