Download a printable version of the member application. Contractor Member Application Name First Last Company Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Website Logging ContractorLogging Contractor - responsible for stump to roadside –eligible for Board Membership, voting member, dividend eligible.* Membership dues for 2021 are based on 2020 production (tons delivered 1/1/20 – 12/31/20) Please check the box that applies to your company. $250 (25,000 tons and under) - $200 if Master Logger Certified $500 (25,001 tons to 50,000 tons) - $400 if Master Logger Certified $750 (50,001 to 100,000 tons) - $650 if Master Logger Certified $1000 (100,001+ tons) - $900 if Master Logger Certified Affiliated ContractorAffiliated Contractor: includes sole proprietor w/ pre-determination letter (must be Master Logger certified), owner-operator/sub-contractor, chipping contractor, grinding contractor, slashing contractor or chip mill – voting member, dividend eligible*, not eligible for Board membership. Membership dues for 2021 are based on 2020 production (tons delivered 1/1/20 – 12/31/20) Please check the box that applies to your company. $250 (25,000 tons and under) - $200 if Master Logger Certified $500 (25,001 tons to 50,000 tons) - $400 if Master Logger Certified $750 (50,001 to 100,000 tons) - $650 if Master Logger Certified $1000 (100,001+ tons) - $900 if Master Logger Certified Forest ContractorForest Contractor – Trucking Only or Forest Road Construction: 50% or more of business is from forestry operations – voting member, dividend eligible*, not eligible for Board membership. Membership dues for 2021 are based on 2020 data (number of employees 1/1/20 – 12/31/20) Please check the box that applies to your company. 0-2 employees -$100 3-5 employees - $250 6-10 employees - $500 11+ employees - $750 The undersigned, on behalf of the above-named company (applicant), herby applies for membership in the PLC of Maine. As a condition of membership, I agree that: - The burden of proof for eligibility rests with the applicant and all questions must be completed. 1. Is your company responsible for the execution of all phases of your harvesting operation from stump to roadside? Yes No 2. Do you have a Federal Tax ID #? Yes No 3. Do you have an Unemployment Insurance Account Number? Yes No 4. Do you have a current Workers’ Compensation Policy? Yes No * PLC policy is that Members must have a current workers comp. insurance policy. However, affiliated sole proprietor applicants may also qualify for membership if they do not have a current policy by attaching a current "predetermination of independent contractor status" letter from the State of Maine Workers Compensation Board. Sole proprietors must also be Master Logger certified. Workers Comp. Agency (i.e. Chalmers, Clark Insurance, Champoux, Cross, F.A Peabody, Kyes, Readfield Insurance, United - etc.) : Workers Comp. Underwriter (i.e. MEMIC, Acadia-etc.): Workers Comp. Mod. rating (If you don't know it- leave it blank and we will contact your insurance agent): 5. Do you have a current General Liability Insurance Policy?* Yes No General Liability Agency (i.e. Chalmers, Clark Insurance, Champoux, Cross, F.A Peabody, Kyes, Readfield Insurance, United - etc.) : General Liability Underwriter (i.e. Acadia, Acuity -etc.): 6. Current number of employees: 7. Do you participate in a third party certification and/or training program (please check all that apply): Northeast Master Logger Program Certified Logging Professional Program Qualified Logging Professional Program Other 8. Do you have a written safety program on file? Yes No (PLC members must have a written safety program on file as a condition of membership. The PLC will provide sample safety plans to assist with this process.) 9. Do you have ongoing workplace safety inspections? Yes No 10. Have you violated the standards of the Forest Practices Act, the Liquidation Harvesting Rule or had civil violations (i.e. timber theft or trespass) within the past five years? If yes, please explain.11. During the past 12 months, have there been any significant changes in your company? If yes, please explain.Would your company like to participate in the 2021 PLC/Acadia Insurance Dividend Group? (*participation in the Dividend Group is subject to underwriting approval by Acadia Insurance) Yes - (if your answer is yes, please proceed to question 12.) No - (if your answer is no, please proceed to question 13.) 12. Acadia Confidentiality Waiver- As a condition of participation in the PLC/Acadia Insurance Dividend Group, Acadia Insurance requires the PLC to obtain a signed confidentiality waiver from each participating company.On behalf of (“Company”), as a member of the PLC/Acadia Insurance Dividend Program, I hereby authorize Acadia Insurance and/or its appointed agents to release information relating to my insurance policies with Acadia Insurance, including but not limited to premiums and loss history, to the Executive Director of the PLC. The Executive Director of the PLC will keep this information confidential and will not share company specific information with the Executive Board, Full Board, or individual members of the PLC. I acknowledge and agree that the fore- going authorization will remain valid as long as the Company remains a member of the PLC and the PLC/Acadia Insurance Dividend program, unless expressly revoked in writing to Acadia Insurance and the PLC. The undersigned certifies that he/she is duly authorized to sign this authorization on behalf of the Company. Signature required to participate in dividend program13. Loggers Code of Practice: (All PLC members must sign)Loggers Code of Practice: It is understood that all members of the PLC will adhere to its “Logger’s Code of Practice”. As a professional logging contractor, I will strive to operate in such a way as to engender the public’s trust including meeting or exceeding the standards and principles as follows: • Promote ethical conduct for all loggers. • Strive to always meet standards for harvesting practices, which are consistent with the principles of sustainable forestry. • To operate responsibly in all phases of the harvesting operation, from the actual harvesting activities to clean-up requirements following the harvest. • Recognizing private landowner rights, I will strive to meet the landowners objectives as long as they are consistent with sustainable forestry principles, federal, state and local laws. • I will do all I can to educate and inform landowners, loggers and others about the need to meet sustainable forestry principles. • I will participate in the Northeast Master Logger, Certified Logging Professional, Qualified Logging Professional or other third party recognized program that will provide me with recognition as having met the appropriate requirements for logger education and training as envisioned by sustainable forestry principles. •Comply with all federal, state and local laws and regulations, industry standards and guidelines applicable to the conduct of forest harvest operations. • Conduct harvest operations in a safe manner which are in compliance with Occupational Safety and Health Administration regulations including safety planning and all provisions of such requirements. • To operate my company profitably as a responsible member of the business community including compliance with all requirements and practices as they relate to my employees, vendors and others I do business with. • Continually strive to maintain positive relationships with landowners, procurement and mill personnel and the public in general. • Do my part to assure that my industry has a positive image and to work with peer groups, logger associations and others to strive to bring all loggers up to these standards. • Strive to continually improve my operations through training, innovation, employee programs and other appropriate means. • Act responsibly to uphold the integrity of the logging profession. Signature (Type) First Last Company: Title: Date MM slash DD slash YYYY 2021 Dues - We understand PLC’s honor system is based on the membership level as set forth by the PLC Board of Directors on and that any member found not paying fairly for 2020 will be assessed back dues.2021 Dues Amount: Log A Load Donation - Please accept my additional donation on behalf of the Log A Load for Maine kids program. Contributions will be distributed equally between Eastern Maine Healthcare and the Barbara Bush Children’s Hospital.2021 Donation Amount: Total Due: Payment Options: To pay by credit card please check here and we will e-mail you a secure link. I will mail a check to: Professional Logging Contractors of Maine P.O. Box 1036 , Augusta, ME 04332 NameThis field is for validation purposes and should be left unchanged.
