Free 9612Form10T.p65 - Nebraska

To:

Nebraska Workers' Compensation Court P.O. Box 98908 Lincoln NE 68509-8908 (402) 471-6468 (Lincoln & Outstate Only) (800) 599-5155 (Nebraska Only)

NWCC Form 10T (Rev. 12/96)

(For Court Use Only)

CORPORATE EXECUTIVE OFFICER -- TERMINATION OF WAIVER

Executive Officer Name Corporation Name Address Office Held in Corp. I wish to terminate the executive officer waiver which was filed about and become subject to the provisions of the Nebraska Workers' Compensation Law. ,

Date (Officer Signature)

INSTRUCTIONS
1. 2. 3. 4. 5. Type or print in ink clearly. Original must be filed with the Court. A waiver may not be terminated until one year after the waiver has become effective. The termination becomes effective upon receipt by the Court. A copy of the termination must also be filed with the secretary of the corporation. It is advisable that you file one copy with your insurance company and retain one for your files.