Employers Application To Elect Domestic Employees To Come Within Provisions Of The Wokers Compensations Act
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Employers Application To Elect Domestic Employees To Come Within Provisions Of The Wokers Compensations Act Form. This is a Pennsylvania form and can be use in Workers Comp.
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Tags: Employers Application To Elect Domestic Employees To Come Within Provisions Of The Wokers Compensations Act, LIBC-510, Pennsylvania Workers Comp,
LIBC-510 REV 8-02
SUBMIT APPLICATION TO:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF LABOR AND INDUSTRY
BUREAU OF WORKERS’ COMPENSATION
1171 S. CAMERON STREET, ROOM 103
HARRISBURG, PA 17104-2501
EMPLOYER’S APPLICATION TO
ELECT DOMESTIC EMPLOYEES TO
COME WITHIN PROVISIONS OF THE
WORKERS’ COMPENSATION ACT:
SECTION 321
1. Name of Employer _____________________________________________________________________________
2. Address ______________________________________ City ________________________ State ___________
3. Zip Code ____________________________ Telephone Number_____________________________________
4. List employee name, address, and social security number:
(1) Name of Employee ________________________________________ S. S. # ______________________
Address _______________________________________________________________________________
(2) Name of Employee ________________________________________ S. S. # ______________________
Address _______________________________________________________________________________
(3) Name of Employee ________________________________________ S. S. # ______________________
Address _______________________________________________________________________________
(4) Name of Employee ________________________________________ S. S. # ______________________
Address _______________________________________________________________________________
(5) Name of Employee ________________________________________ S. S. # ______________________
Address _______________________________________________________________________________
5. Employer currently has workers’ compensation coverage:
Yes
No
If Yes: Insurance Company _____________________________________________________________________
Policy Number __________________________________ Policy Effective Date ___________________
I, the undersigned employer of the domestic employees named above, do hereby petition the Bureau of Workers’
Compensation, Department of Labor and Industry, to permit me to come within the provisions of the Workers’
Compensation Act of 1915 and the amendments thereto, in accordance with the provisions of Section 321, and
I aver that I have been informed and fully understand that, if this application is granted, I will be bound by all of the
provisions of the Workers’ Compensation Act.
____________________________________________________________
EMPLOYER’S SIGNATURE
____________________________________________________________
PRINT NAME
_______________________________________________________________
DO NOT WRITE BELOW LINE: BUREAU USE ONLY
The application is hereby granted
______________________________________________________________________________
CHIEF OF COMPLIANCE, BUREAU OF WORKERS’ COMPENSATION
______________
DATE
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