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CARRY ELIGIBILITY QUIZ
Nonelection Form
View Non Election Results
REJECTION OF WORKERS COMPENSATION
Rejection Of Workers Form Results
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Information About Employer
Name of Employer:
*
*
Type of Entity:
*
Type of Entity:
Proprietorship
Type of Entity:
Limited Liability Company
Type of Entity:
Limited Liability Partnership
Type of Entity:
Partnership
Address of Employer's Home Office
*
*
Agreements by Individual
Check Either Alternative
Check Either Alternative
(1) I am not electing the employers’ liability coverage.
Check Either Alternative
(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.
Individual Information
Date
*
*
Full Name of Individual
*
*
Email
*
*
City of Residence
*
*
County of Residence
*
*
State of Residence
*
*
Full Name of Witness 1
*
*
Full Name of Witness 2
*
*
Signed
Signed
No
Signed
Yes
Agreement by Employer.
Check either alternative (1) or (2): *
*
Check either alternative (1) or (2): *
(1) The employer does not elect the employers’ liability coverage.
Check either alternative (1) or (2): *
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.
Employer Information
Full Name of Authorized Agent
*
*
Email of Authorized Agent
*
*
Relationship to Employer of Authorized Agent
*
*
City of Residence Emp
*
*
County of Residence Emp
*
*
State of Residence Emp
*
*
Full Name of Witness No. 1
*
*
Full Name of Witness No. 2
*
*
Signed Emp
Signed Emp
No
Signed Emp
Yes
