Free Download Form 29 in Adobe 9 Fill In Format - Vermont

www.labor.vermont.gov

State of Vermont Department of Labor 5 Green Mountain Drive, PO Box 488 Montpelier, VT 05601-0488 (802) 828-2286

Form 29 ­ Rev. 4/06

Application To Exclude Corporate Officers and Corporations From Workers' Compensation Coverage
Officer Exclusion. Vermont law permits corporate officers to exclude themselves from protection under the Vermont Workers' Compensation Act. Only corporate officers may be excluded. Officer refers to the President, Vice President, Secretary of the Corporation, Clerk or Treasurer. Where a Limited Liability Corporation has no officers the members/managers may be excluded. Corporation Exclusion. Vermont law permits a corporation to be wholly excluded from workers' compensation coverage requirements when all of the corporate officers are excluded and the corporation has no employees.1

Legal Name of Corporation: Federal ID Number: Business Name (if different): Address of Corporation: (Street, Rural Route, Box Number) (City/Town, State and Zip Code)
You must attach a NOTARIZED/CERTIFIED copy of the minutes of the Board of Directors meeting if: 1. 2. The applicant is not listed as a designated officer of record with the Secretary of State's office. Attach minutes indicating that the applicant has been elected an officer of the company. The corporation is new or has been in business less than 18months. The minutes must indicate that the directors have approved the exclusion.

The undersigned, an officer of the above-named corporation, elects to be excluded from coverage under the corporation's workers' compensation policy, and not be entitled to the protections provided by Vermont Workers' Compensation Act from the date this application is approved by the Commissioner.

Name of Officer (Print or Type)

Signature of Officer

Position Held in Corporation

Date Signed Note

The records on file in the Secretary of State's office must indicate that the above business is presently incorporated and that its charter has not been revoked. It is your responsibility to provide the information we need in order for us to approve this application in a timely manner. Exclusions, if approved, may take effect no earlier than the date upon which the Commissioner received a COMPLETE application. Please complete the form and return to the Department of Labor, 5 Green Mountain Drive, PO Box 488, Montpelier, VT 05601-0488. After approval, two copies will be returned to you, one for your corporate files and one for submission to the insurance agent.

______________________________________________ Approved

_____________________________________________ Commissioner of Labor or Designee

1

For corporation exclusion you must attach a Form 29 for each corporate officer.