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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 Corporation
Name of Corporation
*
Address of Corporation Home Office
*
Agreements by Individual
Check Either Alternative
*
Check Either Alternative
(1) I reject the employers’ liability coverage.
Check Either Alternative
(2) I decline to reject the employer’s liability coverage.
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 Corporation.
Check either alternative Emp
Check either alternative Emp
(1) The corporation rejects the employers’ liability coverage.
Check either alternative Emp
(2) The corporation declines to reject the employers’ liability coverage.
Corporation 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
