State of New York WORKERS COMPENSATION BOARD NOTICE OF ELECTION OF A CORPORATION WHICH IS REQUIRED TO HAVE COVERAGE FOR ITS EMPLOYEES UNDER THE NEW YORK STATE WORKERS COMPENSATION LAW TO EXCLUDE THE SOLE SHAREHOLDER-OFFICER OR ONE OF THE TWO OR BOTH EXECUTIVE OFFICERS-SHAREHOLDERS OF THE CORPORATION FROM SUCH COVERAGE To: (Print name and address of insurance carrier here.) TAKE NOTICE that under the provisions of Section 54, subdivision 6, of the Workers Compensation Law as amended, the corporation named below elects to exclude the executive officer(s) named below from coverage under the New York State Workers Compensation Law with respect to all the policies issued to the corporation by the insurance carrier named above. Name of Corporation _____________________________________________________________________________________ Address of Corporation ___________________________________________________________________________________ Incorporated Under the Laws of the State of __________________________________________________________________ Type: One-person corp. Two-person corp. (A two-person corporation may elect to exclude one or both executive officers, provided that between them they own all the stock in the corporation, and that each officer owns at least one share ofstock.) ExecutiveOfficer(s) 1. Name _________________________________ Title ___________________________________ to be Excluded from Policy 2. Name__________________________________ Title ___________________________________ CERTIFICATION USE FOR ONE-PERSON CORPORATION I, ___________________________________, certify that I am the sole executive officer of the above-named corporation; that I Name have been since _______________the sole owner of all issued and outstanding stock of the corporation and hold all the offices Date pursuant to paragraph (e) of Section 715 of the Business Corporation Law. (Affix corporate seal below, if you have one.) ____________________________________________ ___________________________ _____________________________ Signature of Officer Date Telephone No. USE FOR TWO-PERSON CORPORATION We, _____________________________ , ________________________________ and _______________________________, Name Title Name _____________________________ certify that we are the two executive officers of the above-named corporation, having been Title duly appointed by corporate resolution; that we have been since ______________ the sole owners of all issued and outstanding Date stock and that each of us owns at least one share of stock of the corporation, and that we hold all of the offices pursuant to paragraph (e) of Section 715 of the Business Corporation Law. (Affix corporate seal below, if you have one.) _____________________________________________ __________________________ ______________________________ Signature of Officer Date Telephone No._______________________________________________________ __________________________________ _______________________________________ Signature of Officer Date Telephone No. THIS ELECTION IS FINAL AND BINDING UPON THE OFFICER(S) NAMED UNTIL CORPORATE REVOKED BY THE CORPORATION. SEAL* See reverse side for relevant portions of Sec. 54, subd. 6 (WCL) *If the corporation does not and Sec. 715, Par. (e) of the Business Corporation Law. have a seal, check here qC-105.51 (1-04) www.wcb.state.ny.us>>>> 2 Section 54, Subdivision 6 of the New York State Workers Compensation Law b. An executive officer of any corporation who at all times during the period involved owns all of the issued and outstanding stock of the corporation and holds all of the offices pursuant to paragraph (e) of section 715 of the business corporation law and who is the executive officer of a corporation having other persons who are employees required to be covered under this chapter shall be deemed to be included in the compensation insurance contract or covered under a certificate of self-insurance unless the officer elects to be excluded from the coverage of this chapter. Such election shall be made by the corporation filing a notice that the corporation elects to exclude the executive officer of such corporation named in the notice from coverage of this chapter. Such election shall be filed with the insurance carrier or the chair in the case of self-insurance upon a form prescribed by the chair of the workers compensation board. Such election shall be effective with respect to all policies issued to such corporation by such insurance carrier as long as it shall continuously insure the corporation and shall be final and binding upon the executive officer named in the notice until revoked by the corporation in accordance with paragraph a of this subdivision. d. Any two executive officers of a corporation who at all times during the period involved between them own all of the issued and outstanding stock of the corporation and hold all such offices, provided, however that each officer must own at least one share of stock, who are the executive officers of such corporation having other persons who are employees required to be covered under this chapter shall be deemed to be included in the compensation insurance contract or covered under a certificate of self-insurance unless one or both the officers elect to be excluded from the coverage of this chapter. Such election shall be made by any such corporation filing a form prescribed by the chair of the workers compensation board with the insurance carrier or the chair in the case of self-insurance giving notice that the corporation elects to exclude one or both of the executive officers of such corporation named in the notice from the coverage of this chapter. Such election shall be effective with respect to all policies issued to such corporation by such insurance carrier as long as it shall continuously insure the corporation and shall be final and binding upon the executive officers as named in the notice until revoked by the corporation. If such election is revoked, it shall be in writing on a form prescribed by the chair and shall be filed with the chair and the insurance carrier. Such revocation shall not be effective until thirty days after such filing. Section 715, Paragraph (e) of the Business Corporation Law Any two or more offices may be held by the same person, except the offices of president and secretary. When all of the issued and outstanding stock of the corporation is owned by one person, such person may hold a