Inclusion/Exclusion Forms

Workers Compensation Inclusion/Exclusion Forms

Countrywide and State forms

• Countrywide

  WC 0009 1007 – MIG Elect-Reject Form

• Alabama

  AL – WC-14 – AL Corporate Officer Exemption

• Alaska

  AK – 171 – AK Petition for Executive Officer Waiver

• Arizona

  AZ SOLE PROPRIETOR WAIVER LETTER

• California

  CA SB189 Professional Corporation Waiver

• CA SB189 LLC partners waiver
• CA SB189 Corporation waiver

• Colorado

  CO – 171 – CO Rejection of Coverage by Corporate Officer of members of an LLC

• 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

• Delaware

  DE – 171 – Delaware Executive Officer Exclusion

  DE – DCRB-EXCL – Delaware LLC Member Exclusion

• Florida

  FL – 171 – Florida Notice of Election of Coverage

• FL – 174 – FL Revocation of Election of Coverage

• Georgia

  GA – 171 – GA Notice of Election or Rejection of Workers Compensation Coverage

• Idaho

  ID – IC52 – ID Election of Coverage

• ID – IC53 – ID Election of Coverage for Sole Proprietor, Individual

• Indiana

  IN 36097 NOTICE FOR WORKER’S COMPENSATION AND OCCUPATIONAL DISEASES COVERAGE

• Iowa

  IA – 14-0061 – IA Corporate Officer Exclusion from Workers Compensation or Employers Liability Coverage

• 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

• Kentucky

  KY – KY Affidavit of Exemption from the KY Workers Compensation Act – Corporation and Partnership

• Louisiana

  LA -LA Notice of Election – Revocation of Coverage

• Maryland

  MD – C-15R – MD Inclusion Form – Sole Proprietors and Partners Election Form

• MD – C-16R – MD Exclusion Form

• Massachusetts

  MA – Form 153 – MA Affidavit of Exemption for certain Corporate Officers or Directors

• Michigan

  MI – 171 – MI Application for Exclusion of Executive Officers of a Corporation or Members-Managers or an LLC

• MI – 172 – MI Application for Exclusion of a Partner, Spouse, Child or Parent

• Mississippi

  MS – MS Notice of Election – Revocation of Coverage

• Missouri

  MO – WC134 – MO Affidavit of Exemption for Worker’s Compensation Insurance

• Montana

  MT – Independent Contractor Exemption Certificate Affidavit Insurance

• MT – Waiver of Workers’ Compensation Benefits Insurance

• Nevada

  NV – D-43 – NV Employees Election to Reject Coverage and Election to Waiver the Rejection of Coverage for Excluded Persons

• NV – D-44 – NV Election of Coverage by Employer and Employer Withdrawal of Election of Coverage
• NV – D-45 -NV Sole Proprietor Coverage

• New Hampshire

  NH – 6WCex – NH Exclusion of Executive Officers or Members

• NH – 6WC-s – NH Supplemental Notice

• New Jersey

  NJ – PP-1B – NJ Notice of Election – Proprietors and Partners

• New Mexico

  NM – 171 – NM Executive Employee Affirmative Election Form

• NM – 172 – NM Election to Accept
• NM – 173 – NM Revocation
• NM – 174 – NM LLC Member Affirmative Election Form

• New York

  NY – C105.51 – NY Notice of Election of a Corporation

• 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

• North Carolina

  NC – NC Notice of Election – Revocation of Coverage

• Pennsylvania

  PA – 171 – PA Application for Executive Officer Exemption from the Provisions of the PA WC Act Section 104

• PA – 172 – PA Executive Officers Declaration

• Rhode Island

  RI – DWC11e – RI Election by Exempt Corporate Officer to Become Subject to Workers’ Compensation

• South Carolina

  SC – Form 5 – SC Corporate Officers Notice to Reject

• 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

• Vermont

  VT – Form 29 – VT Application to exclude Corporate Officers and Corporations from WC Coverage

• Virginia

  VA Rejection of Coverage under the VA WC Act

• VA – 172 – VA Notice Terminating Prior Rejection of Coverage under the VA WC Act