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'0 Class Code Affidavit M ATR1** 4neSource A Vensure Employer Services CompaM This form will address class codes that are commonly miscoded in construction and industrial operations. Miscoding is the intentional or unintentional use and assignment of a class code. They include the following: • 5606: Contractor -Project Manager, Construction Executive, Construction Manager, or Construction Superintendent 8742 - DE951: Salespersons or Collectors -Outside • 8809 (TX -ONLY): Executive Officers NOC-Performing Clerical or Outside Salespersons Duties Only • 8810 - DE953: Clerical Office Employees NOC Please read the following abbreviated NCCI Scopes definitions to understand what is and is not applicable to their assignment. The complete NCCI Scopes Manual description will be provided to you by your PEO provider upon request. Please select, with an X, the Class Code(s) you are requesting be assigned to a co -employee assigned to your business: ❑5606: This classification is available only to project managers, construction executives, construction managers, or constructionsuperintendents having administrative or managerial responsibility for construction or erection projects. When determining eligibility.it is the job duties, and not the job titles, that are the main consideration. Code 5606 does not apply to any person who is directly incharge of, or who is performing any degree of actual construction work. Such person must be assigned to the classification thatspecifically describes the type of work which they are exercising direct supervisory control. A sole proprietor or owner/operator withno employees, working as a subcontractor for the Client Company, would prevent the assignment of this classification to a constructionexecutive because the subcontractor does not have the required job supervisor or foreman to support indirect supervision. 8742 - DE951: Salespersons or collectors are employees engaged in such duties away from the employer's premises. 8742 is notavailable for employees who deliver merchandise. Judgment is necessary in assessing these employees' duties for classificationpurposes since occasional courtesy deliveries of a nominal quantity of merchandise would not preclude them from being classified to8742. When outside salespersons or collectors regularly and frequently perform duties at the premises of their employers, their totalpayroll is assigned to the highest rated classification representing any part of their work. 8809 (TX -ONLY): Executive Officers performing clerical or outside salespersons duties only - not superintendents, foremen orworkers. This classification applies only to executive officers such as the president, vice president, secretary, treasurer or any otherofficer appointed in accordance with the charter or by-laws of the corporation or a professional association. ®8810 - DE953: This classification is available only to clerical/ administrative personnel whose work areas are separated anddistinguishable from all other work areas and hazards of the employer by floors, walls, partitions, counters, or other physical barriers.The duties of a clerical office employee include creation or maintenance of financial or other employer records, handlingcorrespondence, computer composition, technical drafting, and telephone duties, including sales by phone. The clerical office classification continues to apply to a qualified clerical office employee who performs a duty outside of a qualified clerical office areawhen that duty does not involve direct supervision or physical labor and is directly related to that employee's duties in the office. Activities prohibited while assigned to the codes listed above include: delivering, carrying and loading of any work related materials/equipment. Deliveries of a nominal or insignificant quantities by an employee assigned to 8742 is appropriate_ Climbing ladders, operating equipment, quoting work off the ground or on roofs and all other physically demanding work is also prohibited. Ally HR, LLC reserves the right to retroactively apply all payroll for miscoded employees in any policy period when a determination is made that miscoding has occurred. Miscoded employees will be assigned to the highest rated/governing construction code. By signing this affidavit, I am certifying that I have read the full description of the applicable code, as outlined in the National Council on Compensation Insurance (NCCI) Scopes Manual, and that all employees assigned in the aforementioned code(s) are properly classified. Client Company Name: i/alrnce Investment Gmup_I I C PEO Provider Name: MatrixOneSource Client Owner Name: Jason i utman Client Owner Signature: `""' Date: g /21122 Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material tnereto, commits a fraudulent insurance act, which it a crime and subjects the person to criminal and civil penalties. MOSFORM-FULLPEOENROLLMENTPAOK 16 @2020 MatrixOneSource