Proprietor Corporate Officer Form

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Proprietor Partner CorporateOfficer Form

https://www.dvins.com/download%20files/Proprietor_Partner_CorporateOfficer_Form.pdf

Proprietor/Partner/Corporate Officer Form (If not established on DE-9c) To establish the relationship between proprietors, partners, and/or corporate officers to the below referenced company, please complete and return this form. I attest that, although my name does not appear on the DE 9c wage report of the below-named

PARTNER’S, SOLE PROPRIETOR’S OR CORPORATE OFFICER’S …

https://www.floir.com/siteDocuments/OIR-B1-1562.DOC

Partner’s, Sole Proprietor’s or Corporate Officer’s Printed Name Title Signature (Attach copy of proof of identification) Date Office of Insurance Regulation Property & Casualty Forms …

CORPORATE OFFICERS, MEMBERS, MANAGERS, PARTNERS, …

http://www.sls-ins.com/wp-content/uploads/2017/12/Officer-Election-Rejection-Form.pdf

CORPORATE OFFICERS, MEMBERS, MANAGERS, PARTNERS, SOLE PROPRIETOR OR OTHERS ... This form provides documentation of your decision as your state has not promulgated a form for this purpose. The coverage selection indicated below ... Corporation Sole Proprietor Limited Liability Company TYPE OF COMPANY: Partnership Other – Describe:

OFFICE OF INSURANCE REGULATION Property & Casualty …

https://www.floir.com/siteDocuments/OIR-B1-1562.pdf

Property & Casualty Forms and Rates OIR-B1-1562 REV. 07/2003 PARTNER’S, SOLE PROPRIETOR’S OR CORPORATE OFFICER’S STATEMENT Name of Insurance Carrier: Name of Individual or Business Conducting the Audit: (If other than an employee of the Insurance Company) Name of Insured: Policy Number: Policy Period From: to

OFFICE OF INSURANCE REGULATION Property & Casualty …

https://www.travelers.com/iw-documents/business-insurance/fl-form-1561.pdf

Property & Casualty Forms and Rates . S. TATEMENT OF . I. NDIVIDUAL . P. ROVIDING . A. UDIT . I. NFORMATION (Other than Partner, Sole Proprietor or Corporate Officer) Name of Insurance Carrier: Name of Individual or Business Conducting the Audit: (If other than an employee of the Insurance Company) Name of Insured: Policy Number: Policy Period ...File Size: 27KB

Inclusion/Exclusion Forms – AmeriTrust Online

https://support.ameritrustgroup.com/index.php/additional-resources/workers-compensation-inclusionexclusion-forms/

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

ELECTION OR REJECTION OF COVERAGE FOR SOLE …

https://alicunderwriters.com/assets/documents/form-nc-officer-exclusion.pdf

PROPRIETORS, PARTNERS, MEMBERS OF LLC’S AND CORPORATE OFFICERS Note: ** Sole proprietors, partners and members of LLC’s are excluded from the North Carolina workers’ compensation laws and benefits unless coverage is elected in writing.

Forms - TN.gov

https://www.tn.gov/workforce/injuries-at-work/bureau-services/bureau-services/workers--comp-forms.html

Sole Proprietor/Partner Withdrawal of Election Form I-5: LB-0287 LB-0287s: Aviso de Retiro: Coverage. Corporate Officer Election Not To Accept Form I-6: LB-0090: N/A: Coverage. Corporate Officer Withdrawal of Election Form I-7: LB-0288: N/A: Coverage. Exempt Employer Notice of Acceptance Form I-8: LB-0014 LB-0014s: Aviso de Aceptación: Coverage

GEORGIA STATE BOARD OF WORKERS' COMPENSATION

https://sbwc.georgia.gov/sites/sbwc.georgia.gov/files/board_forms/wc010.pdf

The use of this form is required under the provisions of: (A) O.C.G.A. §34-9-2.1 of the Workers' Compensation Law if a corporate officer or limited liability company member elects to reject coverage; (B) O.C.G.A. §34-9-2.2 if a sole proprietor or partner elects to …

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