Application for Exclusion of Officers and Stockholders
Application for Exclusion of Officers and StockholdersF11=NavigateName of Corporation:Address of Corporation:Insurance Company:Policy NumberWe the officers and stockholders of the above mentioned corporation elect to be individually excluded from our Workers’ Compensation Insurance policy:Officer NameSignatureTitle% OwnershipA copy of the corporate board resolution authorizing this exclusion is attached.Subscribed and sworn to before me this ________ day of ____________, 20____. Counter signed by: _________________________________________________.Notary Public of _______________________________ County, _____________________.My commission expires on the ________ day of ____________, 20____.Office use only:Date received by Carrier Company:_____________________Retain ................
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