F213-112-000 Application for Elective Coverage 08-2018 Application for Elective Coverage of Excluded Employments State Fund Accounts Mail To: Employer Services PO Box 44140 Olympia WA 98504-4140 - 902 - Self - Insured Accounts Mail To: Self-Insurance PO Box 44891 Olympia WA 98504-4891 - 902 - The following categories of employment are not included within the mandatory coverage of the Industrial Insurance laws of Washington per Title 51 of the Revised Code of Washington. Indicate the type of coverage See the following page and the RCWs/WACs listed for reporting requirements and definitions of elective coverage. 1. Domestic servants 2. Garde ning, M aintenance, R epair, etc . in or about the employer222s home 3. Casual E mployment away from the E mployer222s hom e and not associated with their business. Provide a brief description of the work being performed: 4. Services in return for A id or S ustenance only. 5. Minor children under 18 years of age on a family farm. 7. Musicians and Entertainers 8. Volunteer Law Enforcement Office r 9. 10. Student volunteers 226 public and private K 226 12 and institutions of higher education 11. Unpaid students in a work - based school - 12. From: To: 13. Newspaper C arriers and F reelance J ournalists 14. Insurance producers or surplus line brokers I, the undersigned, certify that I am authorized to execute this Application of Elective Coverage on behalf of this business, public entity, or nonprofit organization. By signing below, I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct, and further that if coverage is being elected for student volunteers, the student is enrolled as described on page 2 of this form in #10 and participating as a volunteer in a program authorized by a school; and if coverage is being elected for unpaid students, the student is enrolled as described on page 2 in #11 and participating in a work-based learning program authorized by an institution of higher education. Benefits in accordance with Title 51 RCW are to be provided to all persons, now or hereafter working under this optional coverage until 30 days after written notice of cancellation of this election has been received by the department. In case of cancellation, I shall post said notice at least 30 days before the effective date in the RCW 51.12.110 This coverage will not start until the Department Labor and Industries receives this signed notification. Business Name UBI Account ID Business Address City State Zip Code Applicant222s Name Official Position Applicant222s Phone Number Applicant222s Email Address Date Signature American LegalNet, Inc. www.FormsWorkFlow.com F213-112-000 Application for Elective Coverage 08-2018 Excluded Employment Definitions -17- provides that a business that has elected coverage for one of these categories shall report and paid on an hourly, salaried, part time, percentage of profit, or piece work basis in the applicable classification until 30 days after a notice of cancellation is received in writing by the department. Numbers 9, 10, and 11 are exceptions to - 17- and governed by -17-935 . 1. Domestic Servants: 223Any person employed as a domestic servant in the private home of the employer who has less than two employees regularly employed forty or more hours per week in such employment.224 2. Gardening, Maintenance, Repair, etc. in or about the employer222s home: 223Any person employed to do gardening, maintenance, repair, or similar work in or about the private home of the employer.224 3. Casual Employment: 223A person whose employment is not in the course of the trade, business, or profession of his or her employer, and is not in or about the private home of the employer.224 4. Service in return for aid or sustenance only: 223Any person performing services in return for aid of sustenance only, received from any religious or charitable organization.224 5. Minor children under 18 years of age on a family farm: 223Any child under eighteen years of age employed by his parent or parents in agricultural activities on the family farm.224 223Jockeys while participating in or preparing horses for race meets lice nsed by the Washington Horse Racing Commission pursuant to .224 7. Musicians and Entertainers: 223Services provided by a musician or entertainer under a contract with a purchaser of the services, for a specific engagement or engagements when such musicians or entertainers perform no other duties for the purchaser and is not regularly and continuously employed by the purchaser. A purchaser does not include the leader of a group or recognized entity who employs, other than on a casual basis, musicians or entertainers.224 8. Volunteer Law Enforcement (Officers 226 full coverage): A person who is a member o f a law enforcement department and who ition ted as a volunteer by the law enforcement necessarily incurred in performing assigned duties 226 RCW 51.12.140 . (To withdraw this coverage, you must provide the department with written notification 30 days before your desired cancellation date and notify each volunteer law enforcement NOTE: this election shall not apply to emergency service workers as described in Chapter 38.52 RCW , volunteer firefighters, as covered by Chapter 41.24 RCW, or to community service workers covered by Chapter 13.40 RCW . 9. Volunteer Workers: A person who performs any assigned or authorized duties for a city, county, town, special district, municipal corporation or political subdivision of any type, or a private nonprofit charitable organization brought about by one222s own free choice, receives no wages, and is registered and accepted as a volunteer by the municipality or organization for who the work is performed. RCW 51.12.035 and . Volunteer Law Enforcement Officers (Medical Aid only): Any person who is a member of a law enforcement department, and in a position that is not basically clerical or secretarial in natunecessarily incurred in performing assigned duties 226 RCW 51.12.140 . NOTE: this election shall not apply to emergency service workers as described in Chapter 38.52 RCW , volunteer firefighters as covered by Chapter 41.24 RCW, or to community service workers covered by Chapter 13.40 RCW . All other volunteer for any state agency are mandatorily covered. 10. Student Volunteers: A ny enrolled student in a public school as defined in RCW 28A.150.010 , a private school governed under chapter 28A.195 RCW , or a state public or private institution of higher education, who is participating as a volunteer under a program authorized by the school. The student volunteer shall perform duties for the employer without wages. The student volunteer shall be deemed a volunteer even if the student is granted maintenance and reimbursement for actual expenses necessarily incurred in performing his or her assigned or authorized duties. A person who earns wages for the services performed is not a student volunteer. RCW 51.12.170 11. Unpaid Student (Medical Aid only): Includes a ny enrolled student in a state public or private institution of higher education who is participating in an unpaid work-based program authorized by the school. The unpaid student shall perform duties for the employer without wages but receives credit towards completing the school program, certification, or degree in return for the services provided. Unpaid student includes a student in school-sponsored, unpaid work-based learning, including cooperative education, clinical experiences, and internship programs. RCW 51.12.170 12. Community Service Workers: 223Any offender performing community services pursuan t to a court order, or under the provision of Chapter 13.40 RCW for a state agency, county, city, town, or nonprofit organization.224 13. Newspaper Carriers or Freelance Journalists: 223Newspaper carriers or venders who distribute newspapers to residences, businesses, or on the street, and freelance journalists or photo journalists who are paid solely by piece work and use their own equipment.224 14. Insurance producer a s de fined in RCW 48.17.010 or a surplus line broker licensed under chapter 48.15 RCW . American LegalNet, I