Application for Workers' Compensation Coverage

Please read instructions before completing this form.
 
Click here to get Acrobat Reader You will need the Adobe Acrobat Reader to successfully view/print some information. This software is provided free of charge and you may download the latest version by clicking on the 'Get Acrobat Reader' button.

Using electronic Fill-in-the-Blank PDF Forms:

NOTE: Use of PDF Fill-in-the-Blank forms does NOT include online submittal. In addition, completed PDF forms cannot be saved or attached to email messages.
 
This PDF form is available in a fill-in-the-blank format. Users now have the option to complete the PDF forms electronically, instead of manually writing or typing the information on a hard copy version. The completed form can then be printed and sent via standard mail delivery to:
State Workers' Insurance Fund
100 Lackawanna Avenue
P.O. Box 5100
Scranton, PA 18505-5100
The form can be completed in several easy steps.
  • The user opens the PDF form in Acrobat Reader—in the browser or as a standalone product. The user can also save the “blank” PDF form to their computer system and open the form in Acrobat Reader at a later time.
     
  • Once the form is open, the user clicks on the desired entry field and a blinking cursor appears.
     
  • After the information has been entered in the entry field, the user can tab to the next field.
     
  • After all the fields have been completed, the user can print out the page. [NOTE: It may be beneficial to print single pages of the form as completed. Inadvertent disruption or resetting of the form will cause all information to be cleared from the form.]
     
  • If this form is accessed through a shared PC, it may be necessary to clear information from the form before beginning. Form fields can be cleared by selecting the "Clear All Fields" button at the top of the form.
NOTE: If the cursor is blinking in a field, the information in that field will not be printed. Hit your "Return" or "Enter" key and the information will be captured for all completed fields.
 
Users with Adobe Acrobat Professional as opposed to the Free Acrobat Reader, can save entered data for later use as well as submit completed forms via email.

Accessibility Information:

This form is designed to be accessible by persons with disabilities that utilize assistive technology such as Screen Readers. However, if personal assistance is required, please contact SWIF Underwriting at (570)963-4630 for assistance.
 
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