Workers Compensation Inclusion/Exclusion Forms
Countrywide and State forms
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Countrywide
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Alabama
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Alaska
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Arizona
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California
- CA SB189 LLC partners waiver
- CA SB189 Corporation waiver
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Colorado
CO – 171 – CO Rejection of Coverage by Corporate Officer of members of an LLC
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Connecticut
CT – 6B – Coverage Election by Employee who is an Officer of a Corporation or a Member of an LLC
- CT – 6B1 – Coverage Election by Employees who are Members of a Partnership
- CT – 75 – Coverage Election by Sole-Proprietor
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Delaware
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Florida
- FL – 174 – FL Revocation of Election of Coverage
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Georgia
GA – 171 – GA Notice of Election or Rejection of Workers Compensation Coverage
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Idaho
- ID – IC53 – ID Election of Coverage for Sole Proprietor, Individual
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Indiana
IN 36097 NOTICE FOR WORKER’S COMPENSATION AND OCCUPATIONAL DISEASES COVERAGE
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Iowa
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Kansas
KS – 171 – KS Election of Individual, Partner, Member of an LLC or Self-Employed Individual
- KS – 172 – KA Cancellation of Election of Individual, Partner, Member of an LLC or Self-Employed Individual
- KS – 173 – KS Cancellation of Election Not to Accept Coverage
- KS – 174 – KS Election Not to Accept Coverage
- KS – 176 – KS Election of Employer to Cover Employees
- KS – 177 – KS Election of Coverage for Volunteer Workers
- KS – 178 – KS Cancellation of Election of Employer to Cover Employees
- KS – 179 – KS Cancellation of Election of Coverage for Volunteer Workers
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Kentucky
KY – KY Affidavit of Exemption from the KY Workers Compensation Act – Corporation and Partnership
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Louisiana
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Maryland
MD – C-15R – MD Inclusion Form – Sole Proprietors and Partners Election Form
- MD – C-16R – MD Exclusion Form
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Massachusetts
MA – Form 153 – MA Affidavit of Exemption for certain Corporate Officers or Directors
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Michigan
- MI – 172 – MI Application for Exclusion of a Partner, Spouse, Child or Parent
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Mississippi
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Missouri
MO – WC134 – MO Affidavit of Exemption for Worker’s Compensation Insurance
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Montana
MT – Independent Contractor Exemption Certificate Affidavit Insurance
- MT – Waiver of Workers’ Compensation Benefits Insurance
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Nevada
- NV – D-44 – NV Election of Coverage by Employer and Employer Withdrawal of Election of Coverage
- NV – D-45 -NV Sole Proprietor Coverage
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New Hampshire
- NH – 6WC-s – NH Supplemental Notice
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New Jersey
NJ – PP-1B – NJ Notice of Election – Proprietors and Partners
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New Mexico
- NM – 172 – NM Election to Accept
- NM – 173 – NM Revocation
- NM – 174 – NM LLC Member Affirmative Election Form
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New York
- NY – C105.32 – NY Notice of Election of a Partnership or Sole Proprietorship to bring Partners or Self-Employed Persons under the coverage of the NY WC Law
- NY – C105.52 – NY Notice of Election of a Not-For-Profit Corporation/Association to exclude an unsalaried Executive officer under the coverage of the NY WC Law
- NY – C105.53 – NY Revocation of Election of an Incorporated Religious, Charitable, or U.S. War Veterans Organization to bring Executive Officers under the coverage of the NY WC Law
- NY – C105.55 – NY Revocation of Election of a Corporation to exclude sole Shareholder-Officer or one or both Executive officers under the coverage of the NY WC Law
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North Carolina
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Pennsylvania
- PA – 172 – PA Executive Officers Declaration
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Rhode Island
RI – DWC11e – RI Election by Exempt Corporate Officer to Become Subject to Workers’ Compensation
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South Carolina
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Tennessee
TN – I-4 – TN Election of Sole Proprietor or Partner to come within the provisions of the TN WC Law
- TN – I-6 – TN Notice of Corporate Officer to Employer of Election not to accept provisions of WC Act of TN rev 09_2010
- TN – I-7 – TN Notice of Corporate Officer’s Revocation of Exemption
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Vermont
VT – Form 29 – VT Application to exclude Corporate Officers and Corporations from WC Coverage
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Virginia
- VA – 172 – VA Notice Terminating Prior Rejection of Coverage under the VA WC Act