Free INSURANCE NOTICE - Alaska

INSTRUCTIONS FOR PETITION FOR EXECUTIVE OFFICER WAIVER
No. 1. No. 2. No. 3. No. 4. Provide the exact legal corporate name as it appears on the Certificate of Incorporation, and the corporation's federal employer identification number (federal tax ID number). Provide the corporate mailing address. This is the address where the original waiver should be mailed. Provide the name, mailing address and title of each person for which waiver is sought. Provide the name, address and telephone number of the person completing the application.

A completed Petition for Executive Officer Waiver (Form 07-6131) must be submitted to: Alaska Department of Labor & Workforce Development Workers' Compensation Division P.O. Box 115512 Juneau, Alaska 99811-5512 Telephone: (907) 465-2790 Facsimile: (907) 465-2797

BEFORE A WAIVER CAN BE ISSUED:
A. Each officer must read and sign the Affidavit of Corporate Officers form. Each officer's signature must be signed before a Notary Public. Be advised that the Alaska Corporate Code (AS 10.06) requires each corporation to have at least a President and a Secretary. The office of President and Secretary cannot be held by one individual, unless that person is the sole shareholder. The following items must be included with the Petition for Waiver and Affidavit of Corporate Officers: A copy of the page(s) of the most recently adopted corporate by-laws, including the articles or sections that describe the officers' titles and duties; and A copy of the minutes of corporate meeting, verifying the petitioner's election or appointment as an executive officer. C. If the corporation's status is not current with the Alaska Division of Corporations, Business, and Professional Licensing, a Certificate of Compliance must accompany the petition. If you are unsure of your corporate status, contact the licensing section at (907) 465-2534. The names of the executive officers contained in the petition will be verified against the records of the Alaska Division of Corporations, Business, and Professional Licensing. If there is a discrepancy, the petition may be held in pending status until the corporation updates its officer and director information with the licensing section.

B.

D.

A waiver will not be approved until all information requested has been received by the Workers' Compensation Division. A waiver

cannot be issued retroactively. AMENDING EXISTING WAIVERS
To add or change executive officers, a new waiver application, form 07-6131 must be submitted. The petition must state the names, titles and addresses of each new executive officer or for each officer whose title has changed. An affidavit form must be signed and notarized by each individual listed in the petition. The application for amended waiver must be accompanied by a copy of page(s) of minutes of corporate meeting that reflects the changes in corporate officers. To delete an executive officer from a waiver, or cancel a waiver, the corporation must submit a written request to have the officer removed or the waiver cancelled. The request must be signed by the person who was covered under the waiver, or by the president of the corporation.

Form 07-6131 (Revised 8/15/2007)

PETITION FOR EXECUTIVE OFFICER WAIVER
ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Workers Compensation Board P.O. Box 115512 Juneau, AK 99811-5512 (For AWCB Use Only)

(Type or Print)

An executive officer of a business corporation (AS 10.06), a cooperative corporation (AS 10.15), an electric and telephone cooperative corporation (AS 10.25), or a professional corporation (AS 10.45) may waive their rights to benefits under the Alaska Workers' Compensation Act (AS 23.30). To receive an Executive Officer Waiver, the following completed form and attachments must be submitted to the State of Alaska, Department of Labor & Workforce Development at the above address. An executive officer means the president, vice-president, secretary, treasurer, or a corporate employee who is responsible for the corporation's affairs generally, has a close connection to the board of directors and other officers, and who is specifically designated as an executive officer in the corporation's minutes of record.

1. Legal Name of Corporation

2. Federal Employer Identification No.

3. Mailing Address of the principal business offices of the corporation 4. Name, corporate title, and mailing address of each person for whom an Executive Officer Waiver is requested. (Attach a separate sheet of paper if more space is needed) Name Name Title Mailing Address Title Mailing Address

Name Title Mailing Address

Name Title Mailing Address

5. Name of Person Completing This Form

6. Telephone Number

Each officer listed must sign and have notarized the enclosed Affidavit of Corporate Officer form. This Application must be accompanied by A copy of the page or pages of the bylaws that state officer titles and duties A copy of the page of the minutes of the corporate meeting that reflects the election or appointment of the designated individuals as corporate executive officers
Form 07-6131 (Revised 8/15/2007)

AFFIDAVIT OF CORPORATE OFFICERS Legal Name of Corporation
I, _________________________________________, being first duly sworn, state I am a duly elected or appointed officer of the above named corporation. I request a waiver from coverage under the Alaska Workers' Compensation Act. I am voluntarily, without coercion, signing this waiver request. I understand that my rights to benefits under the Act are waived and that this waiver extends to my beneficiaries in case of my death from any injury sustained during the performance of my duties as a corporate executive officer. I, _________________________________________, being first duly sworn, state I am a duly elected or appointed officer of the above named corporation. I request a waiver from coverage under the Alaska Workers' Compensation Act. I am voluntarily, without coercion, signing this waiver request. I understand that my rights to benefits under the Act are waived and that this waiver extends to my beneficiaries in case of my death from any injury sustained during the performance of my duties as a corporate executive officer.

Signature Of Officer

Signature Of Officer

Signature of Notary Public Notary Public in and for the State of

Signature of Notary Public Notary Public in and for the State of

Subscribed to me this day of My Commission Expires:

,

.

Subscribed to me this day of My Commission Expires:

,

.

I, _________________________________________, being first duly sworn, state I am a duly elected or appointed officer of the above named corporation. I request a waiver from coverage under the Alaska Workers' Compensation Act. I am voluntarily, without coercion, signing this waiver request. I understand that my rights to benefits under the Act are waived and that this waiver extends to my beneficiaries in case of my death from any injury sustained during the performance of my duties as a corporate executive officer.

I, _________________________________________, being first duly sworn, state I am a duly elected or appointed officer of the above named corporation. I request a waiver from coverage under the Alaska Workers' Compensation Act. I am voluntarily, without coercion, signing this waiver request. I understand that my rights to benefits under the Act are waived and that this waiver extends to my beneficiaries in case of my death from any injury sustained during the performance of my duties as a corporate executive officer.

Signature Of Officer

Signature Of Officer

Signature of Notary Public Notary Public in and for the State of

Signature of Notary Public Notary Public in and for the State of

Subscribed to me this day of My Commission Expires:

,

.

Subscribed to me this day of My Commission Expires:

,

.

Form 07-6131 (Revised 8/15/2007)