Free libc-510 - Pennsylvania

LIBC-510 REV 8-02 SUBMIT APPLICATION TO: COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501

EMPLOYER'S APPLICATION TO ELECT DOMESTIC EMPLOYEES TO COME WITHIN PROVISIONS OF THE WORKERS' COMPENSATION ACT: SECTION 321

1. Name of Employer _____________________________________________________________________________ 2. Address ______________________________________ City ________________________ State ___________ 3. Zip Code ____________________________ Telephone Number_____________________________________ 4. List employee name, address, and social security number: (1) Name of Employee ________________________________________ S. S. # ______________________ Address _______________________________________________________________________________ (2) Name of Employee ________________________________________ S. S. # ______________________ Address _______________________________________________________________________________ (3) Name of Employee ________________________________________ S. S. # ______________________ Address _______________________________________________________________________________ (4) Name of Employee ________________________________________ S. S. # ______________________ Address _______________________________________________________________________________ (5) Name of Employee ________________________________________ S. S. # ______________________ Address _______________________________________________________________________________ 5. Employer currently has workers' compensation coverage: Yes No

If Yes: Insurance Company _____________________________________________________________________ Policy Number __________________________________ Policy Effective Date ___________________ I, the undersigned employer of the domestic employees named above, do hereby petition the Bureau of Workers' Compensation, Department of Labor and Industry, to permit me to come within the provisions of the Workers' Compensation Act of 1915 and the amendments thereto, in accordance with the provisions of Section 321, and I aver that I have been informed and fully understand that, if this application is granted, I will be bound by all of the provisions of the Workers' Compensation Act.

____________________________________________________________ EMPLOYER'S SIGNATURE

____________________________________________________________ PRINT NAME

_______________________________________________________________ DO NOT WRITE BELOW LINE: BUREAU USE ONLY The application is hereby granted ______________________________________________________________________________
CHIEF OF COMPLIANCE, BUREAU OF WORKERS' COMPENSATION

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