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Instructions for Completing a SWIF Application and Estimating Premium for Workers’ Compensation Insurance

Effective May 1, 2018

The Mandatory Terrorism Endorsement (TRIA) Is: $0.06 (6 Cents)

The Mandatory Commercial Catastrophe is: $0.03 (3 cents)
The Employer’s Assessment Fee Is 2.17 percent (.0217)

To estimate your premium:

(If you have more than one classification, figure each class separately in steps 1-3, then combine)


  1. Estimate your total gross annual payroll (12 months).

  2. Divide total annual payroll by 100 (Payroll Amount).

  3. Multiply payroll amount x class rate.

  4. Multiply payroll amount x .09 (terrorism and commercial catastrophe).

  5. Add totals for lines 3 and 4 (This is your annual estimated premium).

  6. If the total is less than the minimum premium, you will pay the minimum, if the total is higher, you will use the higher premium. If the total is under $2,000.00 you must pay the premium in full to begin the policy.

  7. Now multiply your premium (either the minimum or your estimate) x .0217 to calculate the Employer’s Assessment Fee.

  8. The sum of #’s 5 and 7 is your estimated premium, which may be adjusted by an underwriter by applying an Experience Modifier or Merit Rating (if applicable) at the time of processing.

For Coverage, submit the following:

A completed, signed application

  • For policies less than $2,000, total payment is required. For policies greater than $2,000, a check for 25 percent of the premium OR the minimum premium, whichever is greater, and include the Employer’s Assessment Fee, Terrorism Fee and Commercial Catastrophe Fee.
  • Please be prepared for a delayed response due to the high volume of applications being received at SWIF. If your application is submitted without a down payment/for a quote, it will not take effect until the day after receipt of payment.
  • SWIF does not offer waiver of subrogation endorsements.

Policy will take effect the day AFTER we receive these Items in the SWIF office, unless you specify a later date. We cannot backdate a policy.

Application for Workers' Compensation Coverage

APPLICATION INFORMATION CHECKLIST

  • Has the check been written out correctly (endorsed to SWIF) and signed? Do the written and digit numbers match?

  • Please note the down payment:
    • All policies less than $2,000 - TOTAL PAYMENT REQUIRED.
    • All policies $2,000 to $10,000 - 25% OF TOTAL PREMIUM, OR MINIMUM PREMIUM, WHICHEVER IS GREATER, with the remaining balance due in four (4) equal installments.
    • All policies over $10,000 - 25% OF TOTAL PREMIUM, OR MINIMUM PREMIUM, WHICHEVER IS GREATER, with the remaining balance due in ten (10) equal installments.
    • Example minimum premiums for:
      • Clerical, $576
      • Sales, $576
      • Residential Carpentry, $2359
      • Commercial Construction, $1838
      • Trucking, $1806
      • Roofing $2873
      • Current rates and class codes available on website www.dli.pa.gov/swif

  • If a balance is due on a previous policy, full payment must be submitted. If you need to inquire about a payment plan, call our main number at 570-963-4635 and ask to speak with Credit and Collections

  • Is the complete mailing address given?

  • Did you provide the Pennsylvania operating location/address?

  • A Federal Identification number (FEIN) must be provided if you have employees. If you do not have a FEIN, you may apply on the IRS website (www.irs.gov). Only in the rare instance when a Sole Proprietor is to be included at the Officer/Owner’s minimum or above (see SWIF form POL115A/51A) and has no employees will we accept a Social Security number in question #2.

  • To combine entities on a single policy or to inform of an ownership change, include a completed ERM-14 Form

  • Has this business entity been insured with SWIF before or have any of the principles of this business entity been associated with any business previously insured by SWIF?

  • Question #10 must be completed with a detailed description of the day-to-day operations of the business.

  • Are the employees’ daily job duties provided in detail on #10?

  • SWIF may require one or more of the following based on the coverage:
    • List of Clerical employees
    • Volunteer Fire Department Roster (Act 46) and Volunteer Fireman Exposure form
    • List of the names and Social Security numbers for any domestic workers.
    • Request to Exempt Certain Religious Members (form LIBC-14B) www.wcais.pa.gov
    • Letter of Certification Approval from the Bureau of Workers’ Compensation (Safety Credit)

  • Please note that SWIF does not provide Waivers of Subrogation, All States Endorsements, Jones Act coverage (Merchant Marine Act).

  • Certificates of Insurance must be provided proving that any subcontractors used carry their own workers’ compensation insurance in Pennsylvania. If valid Certificates of Insurance cannot be provided, the enclosed Independent Contractor Questionnaire must be completed. Any subcontractors that do not carry workers' compensation may be included.

  • A signed copy of the contract between the business and each subcontractor must be provided per Act 72
    • A current copy of active/current Contractor's License (HIC) from the PA Attorney General is required if residential work is being done

  • Is Question #3A or 3B completed in full leaving no blank fields? 100% of ownership and social security numbers are required, as well as the owner’s classification and status
    • We will not write a policy under class codes 951 (sales) or 953 (office) when the nature of the business has an authorized governing class code.
    • Policies are classified according to the nature of the business
    • Please reference POL 115A/51A Voluntary Election of Coverage for an appropriate guideline for minimum payroll required to include an owner.

  • Officer Exclusion forms are needed to exclude owners/corporate officers from coverage
    • Corporations: LIBC-509 & LIBC-513 (Officer Exception forms found on dli.pa.gov Forms tab.) Coverage choice cannot be changed during the policy term.

  • Voluntary Election of Coverage form must be completed indicating whether owner is electing or declining coverage at this time. Coverage choice cannot be changed during the policy term.
    • Sole Proprietors, Members of LLC’s, LLP’s, Partners of a Partnership: POL 115A/51A Voluntary Election of Coverage forms

  • Did the Owner or Corporate Officer sign page one and #18 of page six of the application?

  • Is #19 signed by both the Owner and Broker? Both must sign #19 to endorse the Broker of Record

  • Include I-9 or W-4 forms of the employees or a list of names and social security numbers

  • Include a completed Independent Trucking Questionnaire if you have indicated you use independent drivers

  • If the business is a temporary staffing agency, provide an Alternate Employer Worksheet providing each of your clients’ names, addresses, governing classes, number of temporary workers sent and the estimated payroll per client. NOTE: If you fail to advise us of a client where temporary workers are sent, any claims incurred at said client will be denied. In addition, SWIF will NOT accept a client whose business is also that of a temporary staffing agency as we will not include second level temporary agencies in coverage.

  • If this business contracts with a Professional Employer Organization (PEO) for leased workers, provide a copy of signed contracts and/or agreements from each client as well as a list of employees per contract. If this business itself is a Professional Employer Organization (PEO) please include the requirements which can be found on the SWIF Homepage resources link for PEO requirements

  • If you have a Finance Agreement, include the signed Agreement with the application.

  • Based upon the Workers’ Compensation Act, the carrier must have an insurable interest to write a workers’ compensation policy; having no employees constitutes no insurable interest. If there is no insurable interest provided with the given information, a policy cannot be issued. SWIF is prohibited from issuing a policy on an “if any” basis.

*Policy will take effect the day AFTER we receive these Items in the SWIF office, unless you specify a later date. We cannot backdate a policy.

If you have any further questions, please call 570-963-4635 between the hours of 8 a.m. and 4 p.m.