Workers Compensation Fund Application for Utah Statutory Employee Exclusion Policy Please Print or Type 1 BUSINESS NAME Give Exact or Full Name Years in Business 2 MAILING ADDRESS Business Telephone Number Street or P.O. Box City State Zip Code Fax Number 3 NAMES (INCLUDING DBA'S) AND STREET ADDRESSES OF ALL UTAH LOCATIONS Name Use additional page if necessary Street or Location City Zip Code 4 OWNERSHIP INFORMATION Type of Ownership: Sole Proprietor Corporation Limited Partnership Partnerhip Limited Liability Co. Other Federal Tax ID Number List Below Complete Information For: Sole Proprietor | Partners | Corporate Officers Name ( Last, First Middle Initial) Title % of Ownership S.S.N. Coverage Desired? Yes | No Yes | No Yes | Principle Duties No 5 NATURE OF BUSINESS | DESCRIPTION OF OPERATIONS 6 PREVIOUS INSURANCE COVERAGE? Policy Period from (MO/YR) to (MO/YR) 7 PAYMENT Name Address Authorized Signature WCF 1001-3 (Rev. 9/07) Insurance Company Name Yes No If Yes, please provide information below for last three years Annual Premium Make Check in the Amount of $50.00 Payable to Workers Compensation Fund. Check enclosed Visa Account Number Experience Modifier | OR Mastercard Claims Cost, Including Reserves $20 Service Charge to All Returned Items Please charge credit information below Discover American Exoress Exp. Date American LegalNet, Inc. www.FormsWorkflow.com Workers Compensation Fund Utah Statutory Employee Exclusion Endorsement This endorsement applies only to the insurance provided by the policy because Utah is shown in Item 3.A. of the Information Page. Part One (Workers Compensation Insurance), Part Two (Employers Liability Insurance), Part Three (Other States Insurance) and Part Four (Your Duties If Injury Occurs) of the policy do not apply to the insurance provided by the policy. The policy provides no insurance and no cost is included for the assumption of risk. A premium will be charged to administer and service the policy. The policy is issued in accordance with the provisions of Utah law that authorize exceptions to the application of the statutory employer and statutory employee laws. A copy of this endorsement along with a copy of the Information Page showing this endorsement number in Item 3.D. will serve as evidence of a policy pursuant to §§ 34A-2103 (7)(c)(ii) and 34A-2-103(7)(e)(ii) of the Utah Code. The insured named in Item 1 of the Information Page certifies that it is a partnership, corporation or sole proprietorship customarily engaged in an independently established trade, occupation, profession or business with no employees other than the partners, corporate officer or officers, or owner. As of the effective date of the policy, I, a partner, corporate officer or owner of the insured named in Item 1 of the Information Page, personally waive my entitlement to the benefits provided by the Utah Workers' Compensation Act and the Utah Occupational Disease Act in the operation of the partnership, corporation or sole proprietorship and in the operation of the partnership's corporation or sole proprietorship's enterprise under a contract of hire for services. Print or Type Name and Title of Owner, Partner or Corporate Officer Signature of Owner, Partner or Corporate Officer Date Print or Type Name and Title of Owner, Partner or Corporate Officer Signature of Owner, Partner or Corporate Officer Date Print or Type Name and Title of Owner, Partner or Corporate Officer Signature of Owner, Partner or Corporate Officer Date Print or Type Name and Title of Owner, Partner or Corporate Officer Signature of Owner, Partner or Corporate Officer Date Print or Type Name and Title of Owner, Partner or Corporate Officer Signature of Owner, Partner or Corporate Officer Date For your protection, Utah law requires the following to appear on this form: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in the state prison. This endorsement must be signed by each partner or corporate officer or owner who is waiving his or her entitlement to benefits. Attach additional copies of the endorsement if additional signatures are required. WC 4303-01 (Rev. 9/07) American LegalNet, Inc. www.FormsWorkflow.com