Free 36097.FH11 - Indiana


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Pages: 1
Date: March 31, 2009
File Format: PDF
State: Indiana
Category: Workers Compensation
Author: IGONZALES
Word Count: 305 Words, 2,056 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.in.gov/icpr/webfile/formsdiv/36097.pdf

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NOTICE FOR WORKERS COMPENSATION AND OCCUPATIONAL DISEASES COVERAGE
State Form 36097 (R4 / 3-09)

INDIANA WORKERS COMPENSATION BOARD 402 W Washington Street, Room W196 Indianapolis, IN 46204

INSTRUCTION: Please type or print.

Pursuant to IC 22-3-6-1(b) and 22-3-2-9, the Indiana Workers Compensation Board is hereby notified that the undersigned applicant does hereby elect to be covered for workers compensation and occupational diseases under the law.
STATEMENT OF VOLUNTARY ELECTION [IC 22-3-6-1(b)]
Name of applicant Address (number and street, city, state, and ZIP code) Federal Identification number

I certify that I meet the criteria set out in IC 22-3-6-1 (b) (4), (5) or (9), as selected below: (4) Sole Proprietor (5) Partner (9) Member or Manager of a Limited Liability Company
Name of business Address (number and street, city, state, and ZIP code) Name of Insurance carrier Address (number and street, city, state, and ZIP code) Telephone number Nature of business

(

)

I certify that I am actually and actively engaged in said business
Signature of applicant

I, the undersigned, do elect to be covered by the Workers Compensation and Occupational Diseases coverage until I file a request for cancellation of this election.
Date signed (month, day, year)

STATEMENT OF VOLUNTARY ELECTION [IC 22-3-2-9]

FOR: Farm or Agricultural Employees Household Employees Part-time Volunteer Coaches for non-profit corporation Casual Laborers The undersigned hereby voluntarily elects to be bound by the provisions of the Indiana Workers Compensation and Occupational Diseases acts. I understand that I elect to be covered until I file a request for cancellation of this election.
Type of business

Sole Proprietor

Partnership

Corporation

LLC (

Other
Telephone number

Name of Insurance carrier Address (number and street, city, state, and ZIP code) Name of Employer Address (number and street, city, state, and ZIP code) Signature of Employer

)

Federal Identification number

Telephone number

(

)

Date signed (month, day, year)