Free F213-112-000 Application for Elective Coverage of Excluded Employments - Washington


File Size: 90.1 kB
Pages: 2
Date: November 21, 2005
File Format: PDF
State: Washington
Category: Workers Compensation
Author: Forms Management
Word Count: 1,268 Words, 8,228 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.lni.wa.gov/Forms/pdf/213112a0.pdf

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Preview F213-112-000 Application for Elective Coverage of Excluded Employments
DEPARTMENT OF LABOR & INDUSTRIES Olympia WA 98504-4144

APPLICATION FOR ELECTIVE COVERAGE OF EXCLUDED EMPLOYMENTS

The following categories of employment are not included within the mandatory coverage of the Industrial Insurance laws of Washington, Title 51 of the Revised Code of Washington. Please indicate the type of coverage elected by placing an "X" in the appropriate box(es). See reverse side for reporting requirements and definitions of elective coverage. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. DOMESTIC SERVANTS GARDENING, MAINTENANCE, REPAIR, ETC., IN OR ABOUT THE EMPLOYER'S HOME CASUAL EMPLOYMENT AWAY FROM EMPLOYER'S HOME AND NOT ASSOCIATED WITH THEIR BUSINESS SERVICES IN RETURN FOR AID OR SUSTENANCE ONLY MINOR CHILDREN UNDER 18 YEARS OF AGE ON A FAMILY FARM JOCKEY- RACING MUSICIANS AND ENTERTAINERS VOLUNTEER LAW ENFORCEMENT OFFICERS (full coverage) (6905) VOLUNTEER WORKERS (Med Aid only ) check one or both boxes below Law Enforcement (6906) Other (6901) Community Improvement Project (6901) COMMUNITY SERVICE WORKERS (7203) Project period ___________to___________ NEWSPAPER CARRIERS INSURANCE AGENTS, BROKERS OR SOLICITORS STUDENT VOLUNTEERS K - 12 ONLY (Med aid only 6901) Other ________________________________________________________________________ (please explain)

I, the undersigned, certify that I am authorized to execute this Application for Elective Coverage on behalf of this business, public entity or nonprofit organization. Benefits in accordance with Chapter 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 work area of the affected worker(s) and shall personally notify other affected worker(s). (RCW 51.12.110) This coverage will not become effective prior to such time as the Department of Labor & Industries receives this signed notification, pursuant to RCW 51.12.110 or on a later date as indicated here _______/________/____________.
Business Name Business Address Applicant's Name Date UBI City Official Position Signature of Applicant Account ID State ZIP+4

State Fund Accounts; MAIL FORM TO: EMPLOYER SERVICES DEPARTMENT OF LABOR & INDUSTRIES PO BOX 44144 OLYMPIA WA 98504-4144 (360) 902-4817

NOTE:

If your Account ID starts with 700, 701 or 706 Self Insured Accounts; MAIL FORM TO: SELF-INSURANCE SECTION DEPARTMENT OF LABOR & INDUSTRIES PO BOX 44891 OLYMPIA WA 98504-4891 (360) 902-6860

F213-112-000 application for elective coverage

11-03

EXCLUDED EMPLOYMENT DEFINITIONS
WAC 296-17-31021(2) provides that a business that has elected coverage for one of these categories shall report and pay premiums based on 160 hours per month for full time salaried employees or actual hours worked for any employees 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. 1. Domestic servants: "Any 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 each per week in such employment." (Coverage for nursing care is mandatory). 2. Gardening, maintenance, repair, etc., in or about the employer's home: "Any person employed to do gardening, maintenance, repair, or similar work in or about the private home of the employer." 3. Casual employment: "A 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." 4. Services in return for aid or sustenance only: "Any person performing services in return for aid or sustenance only, receive from any religious or charitable organization." 5. Minor children under 18 years of age on a family farm: "Any child under eighteen years of age employed by his parent or parents in agricultural activities on the family farm. " 6. Jockeys-Racing: "Jockeys while participating in or preparing horses for race meets licensed by the Washington Horse Racing Commission, pursuant to Chapter 67.16 RCW." 7. Musicians and Entertainers: "Services provided by a musician or entertainer under a contract with a purchaser of the services, for a specific engagement or engagements when such musician or entertainer performs 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." 8. Volunteer Law Enforcement Officers (full coverage): "Any person who is a member of a law enforcement department, and who (i) performs assigned or authorized duties for the law enforcement department by his or her own free choice; (ii) serves in a position that is not basically clerical or secretarial in nature; (iii) is registered and accepted as a volunteer by the law enforcement department; and (iv) receives no monetary remuneration other than maintenance and reimbursement for actual expenses necessarily incurred in performing assigned duties - RCW 51.12.140." (To withdraw this coverage, you must provide the Department with written notification 30 days in advance of your desired cancellation date and notify each volunteer law enforcement officer affected by the withdrawal.) NOTE: This election shall not apply to emergency service workers as described in Chapter 38.52 RCW, volunteer firemen, as covered by Chapter 41.24 RCW, nor to community service workers covered by Chapter 13.40 RCW. Coverage for medical aid insurance only is available under No. 9 below. 9. Volunteer Workers: (Medical Aid Only) "Any 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 one's own free choice, receives no wages, and is registered and accepted as a volunteer by the municipality or organization for whom the work is performed." RCW 51.12.035 and RCW 51.12.050 (2). Volunteer Law Enforcement Officers (Medical Aid Only): "Any person who is a member of a law enforcement department, and who (i) performs assigned or authorized duties for the law enforcement department by his or her own free choice; (ii) serves in a position that is not basically clerical or secretarial in nature; (iii) is registered and accepted as a volunteer by the law enforcement department; and (iv) receives no monetary remuneration other than maintenance and reimbursement for actual expenses necessarily incurred in performing assigned duties - RCW 51.12.140." NOTE: This election shall not apply to emergency service workers as described in Chapter 38.52 RCW, volunteer firemen as covered by Chapter 41.24 RCW, nor to community service workers covered by Chapter 13.40 RCW. All other volunteers for any state agency are mandatorily covered. 10. Community Service Workers: "Any offender performing community services pursuant to a court order, or under the provisions of chapter 13.40 RCW for a state agency, county, city, town or nonprofit organization." 11. Newspaper Carriers: "Newspaper carriers who sell or distribute papers on the street or from house to house." 12. Insurance Agents, Brokers, or Solicitors: As defined in RCW 48.17.010, 48.17 and 48.17.030. "Persons appointed or authorized by another to solicit and/or procure insurance for themselves or others. " 13. Student Volunteers: As defined in RCW 28A.150.010. "An enrolled student in a public school 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." F213-112-000 (backer) 11-03