Utah Code § 31A-22-1017

Attestation required
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(1) As used in this section, "zero estimated exposure policy" means a policy of insurance that an
employer obtains to cover the employer's liability to pay compensation under Title 34A, Chapter
2, Workers' Compensation Act, or Title 34A, Chapter 3, Utah Occupational Disease Act, after
reporting the employer's total estimated exposure is zero.
(2) An insurer shall require each applicant for a zero estimated exposure policy to sign an
attestation in capital letters with substantially the following form and content: "I ATTEST
THAT ALL INFORMATION PROVIDED IN THIS APPLICATION IS CURRENT, TRUE,
ACCURATE, AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I
FURTHER ATTEST THAT I HAVE NO EMPLOYEES AND AN ESTIMATED EXPOSURE
OF ZERO. IF I EMPLOY ANY EMPLOYEES DURING THE POLICY PERIOD, I SHALL
PROVIDE WRITTEN NOTICE TO MY WORKERS' COMPENSATION INSURER WITHIN 60
DAYS AFTER THE EMPLOYMENT BEGINS, AND INCLUDE THE ESTIMATED PAYROLL
AND CLASSIFICATION CODES FOR THOSE EMPLOYEES. I UNDERSTAND THAT AN
OMISSION OR MISREPRESENTATION MADE WITH INTENT TO DEFRAUD IN THIS
APPLICATION CONSTITUTES A CRIMINAL ACTION."

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