Workers’ Compensation Coverage Exclusion Notice Form

Workers’ Compensation Coverage Exclusion Notice Form
This form serves as an official notice for exclusion from workers’ compensation coverage. Please complete all required information accurately.
Business/Entity Name
Business Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Individual’s Full Name
First NameLast Name
Individual’s Job Title or Position
Reason for Exclusion
Effective Date of Exclusion
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Acknowledgment: I understand and acknowledge that I am electing to be excluded from workers’ compensation coverage as permitted by law.
Signature
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