IC-16 Exclusion Form version 09-2018
WORKERS¡¯ COMPENSATION COMMISSION
EXCLUSION FORM
INSTRUCTIONS: Pursuant to Labor & Employment Article ¡ì9-206, Annotated Code of Maryland,
officers or members of certain business entities may elect to be exempt from workers' compensation
insurance coverage by filing this Exclusion Form with the Commission. To exercise this option, the
officer or member making the election must sign this document, submit the form to the Workers¡¯
Compensation Commission, a copy to the insurer of the company/corporation, and keep a copy for your
files.
Company Name: ______________________________________________________________________
Address: ____________________________________________________________________________
City: _____________________
State: ___________
ZIP _______________________
Type of Company:
___ Close Corporation
___ General Corporation
___ Professional Corporation
___ Limited Liability Company
___ Farm Corporation
Insurance Company Name: _____________________________________________________________
Date Insurance Company Notified:_________________
Typed Name and Title of the Officer
or Member Electing Exclusion
% of
Ownership
____________________________________
________
___________________
____________________________________
________
___________________
____________________________________
________
___________________
____________________________________
________
___________________
____________________________________
________
___________________
Personal
Signature
NOTE: By signing this Exclusion Form, each officer or member affirms under the penalties of perjury
that the information contained in this form is true and correct as to that officer or member, to the best of
the officer¡¯s or member¡¯s knowledge, information, and belief.
10 East Baltimore Street
Form IC-16 (09/2019)
Baltimore, Maryland 21202-1641
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