State of New York THIS AGENCY EMPLOYS AND WORKERS COMPENSATION BOARD SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION. REVOCATION OF ELECTION OF A MUNICIPAL CORPORATION OR OTHER POLITICAL SUBDIVISION OF THE STATE TO BRING EXECUTIVE OFFICERS UNDER THE COVERAGE OF THE NEW YORK WORKERS COMPENSATION LAW. To: CHAIRMAN, WORKERS COMPENSATION BOARD THIS REVOCATION IS EFFECTIVE 30 DAYS AFTER THE DATE FILED To: (Print name and address of insurance carrier here) WITH THE CHAIRMAN, WORKERS COMPENSATION BOARD AND THE INSURANCE CARRIER. TAKE NOTICE that under the provisions of Sec.54, subd. 6, of the New York Workers Compensation Law as amended, the municipal corporation or other political subdivision of the State named below hereby revokes, effective as provided by law, the election now in effect to bring its executive officers described herein within the coverage of the New York Workers Compensation Law, with respect to all policies issued to the corporation by the insurance carrier named above. Name of Municipal Corporation or other political subdivision_____________________________________________________________________________________ Address___________________________________________________________________________________________________ This is a municipal corporation or other political subdivision of the state. EXECUTIVE OFFICERS INCLUDED IN POLICY (INCUMBENT AND SUCCESSOR) Describe either (1) by Name, Address and Title or (2) by Departments, Bureaus or Group or (3) by an all inclusive statement or (4) by other appropriate description. (Typewrite) I,_____________________________________, _________________________ of the herein named municipal corporation or other (Name of authorized person) (Title) political subdivision, certify that the above revocation of election to include executive officers described above, was duly made by the municipal corporation or other political subdivision pursuant to law and that copies of this notice have been filed this day with the Chairman, Workers Compensation Board, the insurance carrier named above and each of the officers concerned. Name of Municipal Corporation or CORPORATE other political subdivision________________________________________________________________ SEAL* Date ___________________________By___________________________________________________ (Signature) *If the corporation or political subdivsion does not have a seal, check here: q NOTE: This form applies only to the executive officers here certified and should be sent at once to the Chair, Workers Compensation Board with copies to the insurance carrier and each of the officers concerned. For copy of Sec. 54, subd. 6, of the law see reverse side. C-105.41 (1-04) www.wcb.state.ny.us>>>> 2 Section 54, Subdivision 6 of the New York Workers Compensation Law 6. a. Insurance of officers of corporations. Every executive officer of a corporation shall be deemed to be included in the compensation insurance contract or covered under a certificate for self-insurance unless that person is an unsalaried executive officer of a not-for-profit corporation or unincorporated association and such corporation or association elects to exclude that person from the coverage of this chapter. Such election to exclude such person shall be writing on a form prescribed by the chair and filed with the insurance carrier. Such election shall be effective with respect to all of the policies issued to the corporation or association by such insurance carrier as long as it shall continuously insure the corporation or association, provided that written notice of the continuation of the election to exclude any or all executive officers is given to the corporation or association with each renewal notice of the policy. 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. Any executive officer whose corporation or association files any election not to be included under this chapter shall be deemed not to be an employee within the intent of this chapter; however, if not excluded, such officers and their dependents shall be entitled to compensation as provided by this chapter. f. Notwithstanding the provisions of paragraph a of this subdivision or any other provision of this chapter, any executive officer of a religious, charitable or educational corporation and the officers of a municipal corporation, and officers of any post or chapter of organizations of veterans of any war of the United States may be brought within the coverage of the insurance contact as if they were employees by any such corporation filing with the insurance carrier, upon a form prescribed by the chair of the workers compensation board, a notice that the corporation elects to bring one or more executive officers of such corporation named in the notice within 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. If such election is revoked, it shall be in writing on a form prescribed by the chair and filed with the chair and with the insurance carrier and a copy thereof furnished to each officer as to whom such revocation is applicable, upon a form prescribed by the chair. Such revocation shall not be effective until thirty days after such filing. The estimation of the wage values of executive officers within the coverage of the insurance contract shall be reasonable and separately stated and added to the valuation of the payrolls upon which the premium is computed. g. The executive officers brought within the coverage of the insurance contract, and the dependents of any such executive officers, including executive officers of religious, charitable or educational corporations and officers of municipal corporations, and officers of any post or chapter or organizations of veterans of any war of the United States that have elected to bring their officers within the coverage of the policy, shall have the same rights and remedies as any employee and shall be entitled to compensation and medical care as provided by this chapter, and the insurance carrier shall be liable therefor and for payments into the special funds provided in this chapter as in the case of an employee. The executive officers who may be brou