Free WC Corporate Exclusions/Inclusions - Alabama


File Size: 13.1 kB
Pages: 1
Date: May 22, 2008
File Format: PDF
State: Alabama
Category: Workers Compensation
Author: mfs
Word Count: 211 Words, 1,980 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dir.alabama.gov/docs/forms/wc_corporate_exclusions-inclusions.pdf

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(WC14/15)

EMPLOYERS NOTICE TO EXCLUDE OR INCLUDE COVERAGE FOR HIMSELF, OFFICERS OR MEMBERS

Part I: OFFICER/MEMBER Per Article 3, 25-5-50(b), Code of Alabama: Notwithstanding subsection (a), an officer of a corporation may elect annually to be exempt from coverage by filing written certification of the election with the department and the employer's insurance carrier. ( ) I, __________________________________ choose to be excluded from my (PRINT FULL NAME) employer's workers' compensation insurance policy. I understand if a job related injury occurs I will not have insurance protection. _________________________________________________ _____ _________ SIGNED DATE TITLE At the end of any calendar year, a corporate officer who has been exempted, by proper certification from coverage, may revoke the exemption and thereby accept coverage by filing written certification of his or her election to be covered with the department and the employer's insurance carrier. ( ) I, ________________________________ choose to be included under my (PRINT FULL NAME) employer's workers' compensation insurance policy. I have previously been excluded as an officer/member. ________________________________________________ ______ ___________ SIGNED DATE TITLE Part II: SOLE-PROPRIETOR OR PARTNERSHIP ( ) I, _____________________________ elect coverage under the Alabama Workers' (PRINT FULL NAME) Workers' Compensation Act. _______________________________________________ ______ ________________ SIGNED DATE TITLE Business Name___________________________________________________________ Mailing Address__________________________________________________________ Physical Location_________________________________________________________ FEIN_____________ UC NUMBER_________________ WC Insurance Carrier_____________________________ Policy No. _______________ Effective Date______________ Agency/Phone__________________________________ THIS DIVISION WILL ONLY ACCEPT ORIGINAL SIGNATURES