Free Application for Exemption from WV Workers' Compensation Coverage 1124 Smith Str... - West Virginia


File Size: 381.3 kB
Pages: 8
Date: September 25, 2008
File Format: PDF
State: West Virginia
Category: Workers Compensation
Author: Ryan Simms
Word Count: 2,308 Words, 16,469 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.wvinsurance.gov/wc/pdf/notices/exemption-application.pdf

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Application for Exemption
from

WV Workers' Compensation Coverage
1124 Smith Street Charleston, WV 25301
Mail Completed Application To: WV INSURANCE COMMISSION Employer Coverage Division PO Box 11682 Charleston, WV 25339-1682 Telephone: 304-558-6279 ALL QUESTIONS ON THIS APPLICATION MUST BE ANSWERED IN FULL. THE APPLICATION MUST BE NOTARIZED AND A $25.00 APPLICATION FEE IS REQUIRED OR THE APPLICATION CANNOT BE PROCESSED. IF YOU HAVE ANY QUESTIONS PLEASE CALL 304-558-6279.
With limited exceptions, as set forth more specifically in W. Va. Code 23-2-1 and W. Va. Code St. R. 85-8-1 et. seq., workers' compensation coverage is mandatory for all employers who employ one or more employees in WV. The Insurance Commissioner will review this application in light of all relevant law in West Virginia relevant to workers' compensation exempt status, and make a decision based up such law as applied to the information states herein and any additional information requested. Therefore, it is strongly advised that before submitting an application for exemption, the applicant be familiar with the applicable law as referenced above, and only make application if the applicant or his or her business believes that that he or she qualify for one of the limited exemptions.

For Insurance Commission Use Only Exemption ID #: Effective Date: Reviewed By: Date:

SECTION I: BUSINESS INFORMATION
NESS IDENTIFICATION

1.

State the Reason(s) for Filing an Exemption Application. This must be a reason or reasons supported by one of the specific exemptions as set forth in W. Va. Code 23-2-1(b)(1) through (8), or stating otherwise that the employer is exempt from West Virginia workers compensation laws because it does not fall under the purview of W. Va. Code 23-2-1(a). Within this section, please account for all of the persons or entities which ever perform work or services in the State of West Virginia on the employer's behalf, but whom the applying employer does not consider to be an "employee" for the purposes of workers' compensation (i.e., the person(s)/entity(s)) is a subcontractor, independent contractor, etc.). Sufficient documentation in support of the claimed exemption should be provided with this application. If coverage is provided in another state on behalf of the applicant, the applicant must attach proof of coverage from that state.

Attach an explanation of why you are requesting an exemption. employees, or last date of employees.

Please provide your number of

2.

Legal Name of Business: Trading As/Doing Business As:

3.

Primary Corporate Address:
Not a Post Office Box Street

City Zip

County

State

Name of Contact Person

Telephone #

Fax #

Contact Person's Email Address

Cell #

4.

Mailing Address:
Street

City Zip

County

State

5.

Primary WV Address:
Not a Post Office Box Street

City

County

State

Zip

Exempt App Rev. 9/25/2008 Page 1

SECTION I: BUSINESS INFORMATION, Continued

6. 7. 8.

Federal ID #: WV Unemployment Compensation Account #: WV State Tax ID #:
Attach Copy of WV Business Registration Certificate

9.

Type of Organization:
Check all that apply

Sole Proprietorship Partnership Limited Liability Corporation Domestic Corporation Foreign Corporation State Agency Municipality Receivership

`S' Corporation Limited Partnership Joint Venture, Corporation Joint Venture, Partnership Association County Agency Trustee For Profit Not for Profit

10. Describe in Detail the Complete Business Operation and Work Process, including the primary type of work that is performed by your Business and its workers. Please provide sufficient documentation with this application to support the representations in this section (i.e., if applicable, professional or industrial licensures, etc.). If out of state employer, include how long you anticipate working or having operations in West Virginia.

11. State Where Incorporated: Date Incorporated: 12. First Date Owner, Partners, Officers, Members Began Working in WV: 13. Date Employees with Workers' Compensation Coverage in Another State Began Working in WV: 14. Do you currently have employees who: (a) Work in, or within the past year, have worked in, the state of West Virginia? (b) Are residents of the State of West Virginia? (c) Are covered by a workers' compensation policy for West Virginia Workers' Compensation benefits? (d) If so please provide a list of all employees on a separate page. (e) Do you anticipate hiring any such employees in the future? If so, please provide an estimated date of hire? 15. List ALL Licenses, Permits & Certificates Issued by any State Agency for the Purpose of Doing Business in WV:

Provide copy of any certification or license that is required by the state.
Issuing Agency Issued To Type of License, Permit, Certificate License, Permit, Certificate #

16. Did Applicant Purchase or Lease an Existing Business:
If Yes, Answer the Following Questions and Attach a Copy of Purchase/Lease Agreement/Contract

Yes

No

Effective Date of Purchase/Lease: Name of Business Purchased/Leased:
Exempt App Rev. 02/15/08 Page 2

SECTION I: BUSINESS INFORMATION, Continued Address of Purchased/Leased Business:
Street City Zip Contact Person's Telephone # County State

Name of Individual/Contact Person from Whom Business was Purchased/Leased: Address of Individual/Contact Person from Whom Business was Purchased/Leased:
Street City County State zip

SECTION II: SUBCONTRACTOR/INDEPENDENT CONTRACTOR INFORMATION WARNING: The burden of proving independent contractor status of certain individuals is on the employer who is claiming such status. In order to receive a letter of exemption based on independent contractor status, the employer must prove that all the employer's workers are independent contractors (i.e., no employees). Any change or addition in regard to subcontractor/independent contractor status following an approved must be supplied to WV Insurance Commission immediately.

17. Independent Contractor Questions. If you fail to answer these questions, your application will be denied. a. Who owns and/or leases the equipment used to perform your work? b. Who controls your work schedule? c. Does anyone supervise or direct the work you are performing? If yes, please provide details. d. Do you have a written contract for the performance of work? If so, please provide a copy of the contract. e. Do you contract with multiple persons or companies to perform the work described herein or just a single person or company?

18. Do you employ or anticipate employing any subcontractors or independent contractors?

Yes

No

If yes, complete the following for each subcontractor/independent contractor. Attach additional pages if necessary.

Name of Subcontractor/Indep. Contractor # 1: Subcontractor's Workers' Compensation Policy #: Subcontractor's State/Federal Tax ID #: Subcontractor's Address: Street Phone # __________________________ Description of Work Performed by Subcontractor: Estimated Length of Contract: City State County Zip

Exempt App Rev. 02/15/08 Page 3

SECTION II: SUBCONTRACTOR/INDEPENDENT CONTRACTOR INFORMATION, Continued

Name of Subcontractor/Indep. Contractor # 2: Subcontractor's Workers' Compensation Policy #: Subcontractor's State/Federal Tax ID #: Subcontractor's Address:
Street

Phone #________________________ Description of Work Performed by Subcontractor: Estimated Length of Contract:

City Zip

County

State

SECTION III: OWNER, PARTNER, OFFICER, MEMBER IDENTIFICATION AND ELECTIONS OF COVERAGE Pursuant to W. Va. Code 23-2-1(f)(2), workers' compensation coverage is not required for certain sole proprietors, members and officers. For corporations and associations, only the following principal officers are exempt from having to be covered for workers' compensation regardless of whether they work in dual capacity: a president, a vice-president, a secretary and a treasurer. "Dual capacity" is defined as any one person who performs duties and has responsibilities typically associated with an officer, but also performs duties associated with a worker, manager or other employee who is not an officer. 19. List ALL owners, partners, officers, directors, and members. List all individuals who own 10% or more of the business entity. List any persons who have a working relationship with the applicant to provide authority, direction or control over the business operations. `S' Corporations must list ALL individuals legally associated with the `S' Corporation. Provide the name, title or position, social security number and percent of ownership for all individuals listed. Indicate whether the individuals elect not to be covered by WV workers' compensation insurance and whether they work in a dual capacity. Dual capacity is defined as any one person who performs duties and has responsibilities typically associated with an officer, but also performs duties associated with a worker, manager or other employee who is not an officer. Please note that the information provided in this section does not, by itself, entitle the employer to a letter of exemption. The information in this section only serves the purpose of showing that certain individuals serving as sole proprietors, partners and officers for the applying company are exempt from coverage. An employer is not entitled to a letter of exemption from West Virginia workers' compensation coverage unless it meets one of the specific exemptions as set forth in W. Va. Code 23-2-1(b)(1) through (8), or otherwise proves that the employer is exempt from West Virginia workers compensation laws because it does not fall under the purview of W. Va. Code 23-2-1(a). For example, if an employer has several employees that meet the exemption under this section, but several that do not, it would not be entitled to an exemption letter the employer would still need to show its entitlement to an overall exemption under the provisions of 23-2-1(a) or (b).

Name

Title / Position

Effective Date Title / Position Held

SSN

% Owned

Elect Coverage? (Yes / No)

Dual Capacity? (Yes / No)

Exempt App Rev. 02/15/08 Page 4

SECTION IV: SIGNATURE AUTHORITY 20. This application must be signed and sworn to by the appropriate persons listed below.
Signatures of accountants or agents are not acceptable.

a) b) c)

If the applicant is a corporation or a limited corporation this application may be signed by the president or the vicepresident and secretary of the corporation. If the applicant is a partnership or limited liability company this application must be signed by all general partners or members. If the applicant is a limited partnership the application must be signed by all general partners. If the applicant is a sole proprietorship this application must be signed by the sole owner.

I hereby swear or affirm that to the best of my knowledge and belief these statements and representations are true and accurate. I accept the provisions of the WV Workers' Compensation Act and the Rules promulgated thereunder, as amended. I am aware that I MUST timely notify the WV Insurance Commission in writing, of any changes in our business operations, including but not limited to employment of even one person; entering into contracts with subcontractors; change in business type; location; ownership; covered/non-covered status of individual owners, partners, officers, and members; and the status of the business as described in this application. I further realize that all businesses are subject to and ongoing right to inspect and audit in order to maintain exempt status. Pursuant to this ongoing right to inspect and audit, I understand that the Insurance Commissioner may, at any time, request for inspection any documents deemed necessary to confirm that my exempt status is valid, including, but not limited to, tax documents, payroll documents, and financial documents. I understand that my failure to comply with any request for documents may result in the immediate revocation of my exempt status. I further understand that in accordance with W.Va. Code 61-3-24e(5), it is a felony to knowingly and willingly make false statements respecting any information required to be provided under the WV Workers' Compensation Code Chapter 23. Upon conviction the individual shall be confined in a penitentiary for up to three years, fined up to $10,000, or both.

Signature # 1:

Title:

Print Name of Signatory: State of ___________________________, County of ____________________, To Wit: Subscribed and sworn to before me this ________ day of _______________________ 20_____

______________________________________ Notary Public My Commission Expires: __________________

Signature # 2: Print Name of Signatory:

Title:

State of ___________________________, County of ____________________, To Wit: Subscribed and sworn to before me this ________ day of _______________________ 20_____

______________________________________ Notary Public My Commission Expires: __________________

Exempt App Rev. 02/15/08 Page 5

SECTION V: SIGNATURE AUTHORITY SECTION IV: SIGNATURE AUTHORITY , Continued

Signature # 3: Print Name of Signatory:

Title:

State of ___________________________, County of ____________________, To Wit: Subscribed and sworn to before me this ________ day of _______________________ 20_____

______________________________________ Notary Public My Commission Expires: __________________

Signature # 4: Print Name of Signatory:

Title:

State of ___________________________, County of ____________________, To Wit: Subscribed and sworn to before me this ________ day of _______________________ 20_____

______________________________________ Notary Public My Commission Expires: __________________

REMEMBER TO INCLUDE ALL REQUESTED DOCUMENTATION.

Exempt App Rev. 02/15/08 Page 6

Addendum to Application for Exemption from WV Workers' Compensation Coverage for Individual Subcontractors/Independent Contractors

I, _____________________________, understand that I am performing services for
[state individual name]

______________________________ as an independent contractor and not as an
[state company name]

employee. Specifically, I am performing the following independent contractor services for ____________________________:
[state company name]

State services being performed here: _______________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________

I

understand that if I were injured in performing the above services for I would not be provided any workers'
[state company name]

____________________________,

compensation benefits by ___________________________, nor from the West
[state company name]

Virginia Uninsured Employer's Fund, and that if I wish to be provided workers' Compensation benefits in the event of
[state company name]

an injury while working

for

____________________________, I must obtain workers' compensation insurance on my own.

Additionally, I state that my business currently has no employees. I understand that if my company employs other individuals in the future, I will be responsible for providing them West Virginia Workers' Compensation benefits as required by law. I further understand that as a requirement to being an Independent Contractor, I may be required to obtain certain licenses, certificates, etc. from other West Virginia State Agencies and otherwise comply with all West Virginia State Laws regarding my business. Finally, I understand that making any false statements or knowingly making misrepresentations to the Offices of the Insurance Commissioner pursuant to an

application for a letter of exemption from workers' compensation and this Addendum can subject me to severe civil and criminal penalties, including being convicted of a felony.

__________________________________ Signature (Independent Contractor) Tax ID# __________________________ Telephone # _______________________

__________________ Date

__________________________________ Signature (Primary Contractor)

__________________ Date

State of ___________________________, County of __________________, To Wit: Subscribed and sworn to before me this __________ day of __________20___

____________________________________ Notary Public

My Commission Expires ______________