APPLICATION FOR INSURANCE EMPLOYER SERVICES / PHS DIVISION SFN 5556 (05/2016) 1600 E Century Ave, Ste 1 PO Box 5585 Bismarck ND 58506-5585 Telephone 800-777-5033 Fax 701-328-3750 TTY (hearing impaired) 800-366-6888 Fraud and Safety Hotline 800-243-3331 www.workforcesafety.com For WSI use only Employer account number Effective date of coverage Expiration date - payroll period NAICS SECTION 1 ­ General business information Legal name of entity or individual Website address First date employee(s) worked or are expected to work in ND Attention Business mailing address (street address) City Physical business address, if different than mailing address City Contact information Contact (first name) Title Telephone number Suite/apartment State Suite/apartment State ZIP code PO Box ZIP code Trade name of business or DBA (if different from legal name) Federal Tax ID Unemployment account number Date operations will begin/began in ND (Last name) Email address Cell phone number Fax number North Dakota locations - Provide address of other ND locations if different from the mailing address above. No PO boxes please. (additional sheets may be attached) Address City State ZIP code Telephone number SECTION 2 ­ Third party information Accountant (first name) Telephone number (Last name) Email address Yes No Will you be utilizing the services of a Professional Employer Organization (PEO) or employee leasing company? If yes, please provide their business information Name Address City State ZIP code SECTION 3 ­ Reason for applying Please indicate reason for applying for insurance coverage New or existing business now requesting workers' compensation insurance coverage Change of entity Form continued on next page. Please submit all pages to WSI. P1 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR INSURANCE (cont'd) Legal name of entity or individual Page 2 of 3 SECTION 4 ­ Change of entity If you have indicated a change of entity, please indicate your change below Purchase Complete if applicable Date of acquisition Prior business name City Prior owner's name(s) Reorganization Merger Other What percent of the business did you acquire? Prior business address State ZIP code Prior workers' compensation account number (if known) SECTION 5 ­ 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 entity is an out-of-state corporation or an out-of-state cooperative State of incorporation Date of incorporation SECTION 6 ­ Parent company ­ compete following section if entity has a parent company. If not, skip to section 7. Federal Tax ID Business address Contact person Legal name of officer(s) of parent company Name Title City Contact telephone number Business name State Effective date ZIP code Expiration date Home address, city, state, ZIP code Home telephone number Social Security number Is coverage desired Yes No Yes Yes Yes No No No SECTION 7 ­ Legal name of owners, partners, corporate officers Name Title Home address, city, state, ZIP code Home telephone number Social Security number Is coverage desired Yes No Yes Yes Yes Form continued on next page. Please submit all pages to WSI. No No No P1 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR INSURANCE (cont'd) Legal name of entity or individual Page 3 of 3 Employer's spouse and/or children coverage You must list the employer's spouse and all of the employer's children under the age of 22 who have received or will receive compensation from your business. (Additional sheets may be attached) Coverage for the spouse and children under age 22 is provided by special contract only. Spouse ­ the premium is calculated on the wage cap amount. Children under the age of 22 for payroll period ­ the premium is based on actual wages. Children 22 and older for payroll period ­ wages should be reported along with the other employees. Coverage becomes effective upon WSI's receipt of a completed, signed elective coverage contract. Name of family member Social Security Date of birth Relationship Class code Estimated wages Is coverage number desired? Yes No Yes No SECTION 8 ­ 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 800-777-5033. Place where work is performed Description of work performed Number of employees Estimated payroll (not including owners) (include room and board allowance) SECTION 9 ­ Temporary and incidental coverage Extraterritorial coverage ­ as a general rule, extraterritorial coverage extends to incidental operations lasting fewer than 30 days in a state where the employer has no other significant contacts with that state and those operations do not require the employer to purchase workers' compensation insurance under the laws of that state. Reciprocal coverage ­ WSI currently has reciprocal agreements with seven states: Idaho, Montana, Oregon, South Dakota, Utah, Washington, and Wyoming. These reciprocal agreements allow your ND employees to work in those states on a temporary basis without purchasing workers' compensation coverage in that jurisdiction. The reciprocal agreements for each state vary and may include exclusions. These agreements must be requested by the employer and be approved before becoming effective. 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, indicate the state(s) 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 SECTION 10 ­ Fraud warning 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 liab