1600 EAST CENTURY AVENUE, SUITE 1 PO BOX 5585 BISMARCK ND 58506-5585 Telephone 1-800-777-5033 Fax 701-328-3750 TTY (hearing impaired) 1-800-366-6888 Fraud and Safety Hotline 1-800-243-3331 www.WorkforceSafety.com APPLICATION FOR INSURANCE EMPLOYER SERVICES / PHS DIVISION SFN 5556 (092008) PLEASE TYPE OR PRINT USING BLACK OR BLUE INK FOR WSI USE ONLY Employer Account Number Effective Date of Coverage Expiration Date - Payroll Period GENERAL INFORMATION Legal Name of Entity or Individual SIC Code NAICS Trade Name of Business or DBA (if different from legal name) Web Site Address Federal Employer I.D. Number First Date employee(s) worked or are expected to work in ND Unemployment Account Number Date Operations will begin/began in ND Will you be utilizing the services of a Professional Employer Organization (PEO) or employee leasing company? If yes, please provide their business name : Will you be using a Temporary Staffing Agency? Yes Yes No No If yes, please provide their business information: Name Address City State Zip Your Mailing Address: (However if you will be utilizing the services of a Professional Employer Organization or employee leasing company, please provide their mailing address here.) Attention To Address Suite/Apt PO Box City Your Business Address: Address City State Zip Same as mailing address above Suite/Apt # PO Box County State Zip North Dakota Locations: Enter address of other North Dakota Locations if different from the Mailing Address above. No PO Boxes please. (additional sheets may be attached) Address City Contact Person: First Name Middle Initial Title Phone P1 State Zip Phone Last Name Email Cell Phone Fax American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR INSURANCE PAGE 2 OF 3 Legal Name of Entity or Individual Outside Accountant: First Name Middle Initial Phone Last Name Email REASON FOR APPLYING Please indicate your reason for applying for insurance coverage: New or existing business and are now requesting workers’ compensation insurance coverage Change of Entity CHANGE OF ENTITY If you have indicated a change of entity, please indicate your change below: Purchase Reorganization Merger Other _______________________________________________ Complete if applicable: Date of Acquisition What percent of the business did you acquire? Prior Owner’s Name(s) Prior Business Name Prior Workers’ Comp Account Number (if known) Prior Business Address TYPE OF ENTITY Choose the entity type that most closely describes your business: Individual Limited Liability Partnership Corporation Cooperative Association Nonprofit Corporation General Partnership Limited Liability Company Sub-S Corporation Limited Partnership Government COMPLETE IF YOU ARE AN OUT-OF-STATE CORPORATION OR AN OUT-OF-STATE COOPERATIVE ASSOCIATION State of Incorporation Date of Incorporation TYPE OF BUSINESS Choose the item that best describes the principal activity of your business (choose only one.): Accommodation and Food Service Administrative and Support and Waste Management and Remediation Services Agriculture, Forestry, Fishing and Hunting Arts, Entertainment, and Recreation Construction Education Services Finance and Insurance Health Care and Social Assistance Information Management of Companies and Enterprises Manufacturing Mining Professional, Scientific, and Technical Services Public Administration Real Estate and Rental and Leasing Retail Trade Transportation Utilities Warehousing Wholesale Trade Other ____________________________________ If Business Type is Construction, check all that apply: Road Construction Steel Construction Building Construction Other _______________________________________________ If Business Type is Transportation, check all that apply: Over The Road Transportation Gravel/Dirt Transportation Are you leased on to another transportation company? If yes, please indicate leasing company name: P1 Grain Transportation Other _______________________________________________ Yes No American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR INSURANCE PAGE 3 OF 3 Legal Name of Entity or Individual NAME(S) OF OWNERS, PARTNERS, CORPORATE OFFICERS Name Title Address Home Phone Soc. Sec. No. % Owned Is Coverage Desired? Yes No Yes No Yes No Yes No EMPLOYER(S) OPTIONAL COVERAGE: (additional sheets may be attached) Coverage for the owner, partner or corporate officers of a business corporation is optional. Check coverage boxes above, if coverage is desired. An employer electing optional coverage will be charged an annual premium based upon the maximum taxable payroll cap. An optional coverage contract will be sent to you. Coverage becomes effective upon WSI's receipt of that completed, signed contract. EMPLOYER'S SPOUSE AND/OR CHILDREN COVERAGE: You must list the spouse and all children under the age of 22 of the employer(s) who have received or will receive compensation from your business. COVERAGE FOR SPOUSE AND CHILDREN UNDER AGE 22 IS PROVIDED BY SPECIAL CONTRACT ONLY. Spouse - Premium calculated on wage cap amount. Children 21 and under for payroll period - Premium based on actual wages. Children 22 and older for payroll period - Actual wages would be reported along with the other employees. Coverage becomes effective upon WSI's receipt of a completed, signed optional coverage contract. (additional sheets may be attached) Name of Soc. Sec. Date of Relationship Class Actual Estimated Is Coverage Family Member No. Birth Code Wages Wages Desired? Yes No Yes No Yes No EMPLOYEE ACTIVITY AND ESTIMATED 12-MONTH PAYROLL (additional sheets may be attached) Describe each unique type of work performed within the business (e.g., clerical office, janitorial, traveling personnel, etc.) List the number of employees engaged in that type of work and estimate the payroll which will be expended for each in the next 12 months. If you need assistance, contact Employer Services for more information at (701) 328-3800 or 1-800-777-5033. Place Where Work Is Performed Description of Work Number of Employees (not Estimated payroll (include Performed including owners) room and board allowance) EXTRATERRITORIAL COVERAGE Do you anticipate having any North Dakota based employee(s) that will travel outside ND for work? Yes No Do you intend to cover your ND based employee(s) under your WSI policy while temporarily working outside ND? Yes No If yes, please indicate those state(s) in which your ND based employee(s) will be working. If no, do you have separate coverage in the state(s) where the employee(s) will be working? Yes No PENALTY FOR FILING FALSE PAYROLL WITH WORKFORCE SAFETY & INSURANCE North Dakota law provides that any employer who willfully misrepresents to WSI the amount of payroll upon which compensation premium is based is guilty of a Class A misdemeanor. If the premium owing exceeds $500, the employer is guilty of a Class C felony. The employer is also civilly liable to WSI in the amount of THREE (3) times the difference between the premium paid and the amount that should have been paid. I acknowledge that I have read this Fraud Warning and understand that failing to secure workers' compensation coverage, filing a false payroll report, or willfully misrepresenting the amount of payroll is a criminal offense. I understand that WSI is relying upon the truth of my statements on this application. I CERTIFY THAT I HAVE NOT FILED ANY FALSE PAYROLL INFORMATION, NOR MADE ANY FALSE STATEMENT, NOR KNOW OF ANY FALSE STATEMENT MADE IN CONNECTION WITH THIS APPLICATION. I declare that the payroll information entered on this report is true, correct, and accurately reflects the identity of owners or officers, and earnings of all covered employees. I have read and understand this Fraud Warning. Signature of owner/officer Printed Name Date Title P1 Phone Email American LegalNet, Inc. www.FormsWorkFlow.com