WORKERS COMPENSATION FUND CODE 5606 QUESTIONNAIRE Please complete and return this form to WCF within 15 days. Fax to (801) 288-8166. This information is needed to properly write your workers’ compensation insurance. 1. Please advise the name and job duties of the individual(s) to be classified under code 5606 Name: Duties: Name: Duties: Name: Duties: 2. Does the individual(s) classified under code 5606 have direct charge of site workers? Yes □ No □ 3. Does the individual(s) classified under code 5606 exercise indirect supervision through foremen or crew leader for insured’s employees or subcontractors? Yes □ No □ 4. Does the individual(s) classified under code 5606 do any of the construction work at any time? (If yes, provide details.) Yes □ No □ Signature of Owner, Partner or Corporate Officer Date Print or Type Name of Insured Policy Number 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 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. Workers Compensation Fund 392 East 6400 South Salt Lake City, Utah 84107 800-446-COMP wcfgroup.com American LegalNet, Inc. www.FormsWorkflow.com