Free PDF - Pennsylvania

UBC-14A REV 1-96

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

SECTION 304.2 APPLICATION FOR RELIGIOUS EXCEPTION OF SPECIFIED EMPLOYES FROM THE PROVISIONS OF THE PENNSYLVANIA WORKERS COMPENSATION ACT

Name of Employer Address Employer is Sole Proprietor Partnership Corporation Nature of Business of Employer
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(a) Total number of all persons employed by this employer (b) Total number of employes for whom exception is sought Employer's Current Workers' Compensation Coverage:

tf self-insurer, effective date of certificate

and Bureau code number

I covered by insurance policy: f
Name of insurance company Name and address of insurance agent, if any
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Policy number Full name of religious sect including division thereof

Policy effective date

Name and address of local leader of above religious sect

Does religious sect above provide, financial or otherwise, for injured or deceased members and Yes No families thereof? List employe member(s), address and social security number, requesting exception under the Pennsylvania Workers' Compensation Act. NOTF: For each employe listed, an executed copy of the "Employe's Affidavit and Waiver of Workers' Compensation Benefits and Statement of Religious Sect" must be attached to this application. S.S. # (1) Name of Employe Address (2) Name of Employe Address (3) Name of Employe Address (4) Name of Employe Address S.S. # S.S. # S.S. # and attach separate list(s). S.S. # S.S. #

(5) Name of Employe
Address (6) Name of Employe Address N T : If additional employes, check here OE

8. List employes requesting exception who have been granted a similar exception from coverage under the Federal Social Security System and attach a copy of the approved Internal Revenue Service Form 4029, if available: (1) Name of Employe

(2) Name of Employe
(3) Name of Employe

(4) Name of Employe
(5) Name of Employe
(6) Name of Employe

This application must be signed by the employer or, if a corporation, an officer thereof as set forth below.

EMPLOYER

OFFICER AND TITLE

TELEPHONE NUMBER