Free Election of Coverage (IC-52) - Idaho

File Size: 44.7 kB
Pages: 1
Date: June 17, 2009
File Format: PDF
State: Idaho
Category: Workers Compensation
Author: mgale
Word Count: 216 Words, 1,675 Characters
Page Size: Letter (8 1/2" x 11")

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Revocation of Election

The undersigned hereby notifies the Industrial Commission of the following: Household domestic service Casual employment Employment of outworkers Employment of members of an employer's family dwelling in his household. (Applies only to sole-proprietorships) Employment as the owner of a sole proprietorship Employment of a working member of a partnership or a limited liability company (Circle either partnership or Limited Liability Company; if the election applies only to certain partners/members, name the covered partners/members.) Employment of an officer of a corporation who at all times during the period involved owns not less than ten percent (10%) of all of the issued and outstanding voting stock of the corporation and, if the corporation has directors, is also a director thereof (If the election applies only to certain corporate officers, name the covered officers) Employment for which a rule of liability for injury, occupational disease, or death is provided by the laws of the United States Pilots of agricultural spraying or dusting planes Associate real estate brokers and real estate salesmen paid solely by commission Volunteer ski patrollers Officials of athletic contests involving secondary schools (Name of Insurance Company) Policy Number _________________________________________________ Insured Name __________________________________________________ Effective Date of Election/Revocation ________________________ _______________________________________ (Signature of authorized representative) ____________________________________ (Employer's signature)