Workers Compensation Fund URCA Participation Agreement Provided by Workers Compensation Fund for the members of the Utah Roofing Contractors Association Please Print or Type 1 BUSINESS NAME Give Exact or Full Name Policy Number 2 MAILING ADDRESS Street or P.O. Box Business Telephone Number City State Zip Code Fax Number In order to be eligible for the program, I/we agree to adhere to the following: 1 Develop and establish a written safety program. 2 Maintain a safety committee within my organization to assist with implementation of the written safety program, employee safety training and accident investigation. 3 Attendance by management or supervisory personnel at a minimum of two industry-specific safety seminars annually conducted by URCA and/or WCF. 4 Implement safety recommendations offered by WCF. Association members must meet program eligibility criteria established by WCF and the Utah Roofing Contractors Association in order to participate in the program. Termination of membership in the Utah Roofing Contractors Association, failure to comply with participation guidelines, or the expiration or cancellation of workers' compensation coverage through WCF will void this agreement. Should you, for any other reason, elect to terminate this agreement, written notification must be submitted to the Utah Roofing Contractors Association and Workers Compensation Fund. Print or Type Name and Title of Contact Person Signature of Contact Person Date Please retain a copy for your records and give the original to your agent or marketing representative, or send to: Workers Compensation Fund 392 East 6400 South Salt Lake City, Utah 84107 800.446.COMP | Fax: 801.284.88984 www.wcfgroup.com 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. WCF 1018-IC (Rev. 9/07) American LegalNet, Inc. www.FormsWorkflow.com