STATE OF NEW YORK THIS AGENCY EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT WORKERS COMPENSATION BOARD DISCRIMINATION. REVOCATION OF ELECTION OF A NOT-FOR-PROFIT CORPORATION OR A NOT-FOR-PROFIT UNINCORPORATED ASSOCIATION TO EXCLUDE AN UNSALARIED EXECUTIVE OFFICER FROM COVERAGE PURSUANT TO SECTION 54, SUBDIVISION 6 OF THE WORKERS COMPENSATION LAW To: (Print name and address of insurance carrier here) TAKE NOTICE that under the provisions of Section 54, subdivision 6, of the New York Workers Compensation Law as amended, the corporation or association named below hereby revokes, effective as provided by law, the election now in effect to exclude the unsalaried executive officer named below from coverage under the New York State Workers Compensation Law, with respect to all the policies issued to the corporation or association by the insurance carrier named above. Name of Corporation or Association.................................................................................................................................................. Address............................................................................................................................................................................................ Incorporated Under the Laws of the State of (If applicable)............................................................................................................... Executive Officer Included in Policy............................................................................................................................................ (Name) (Title) I certify that the above revocation of election exclude the unsalaried executive officer of said corporation or association was duly made at a meeting of the Board of Directors or other executive body of the corporation or association duly authorized to take such action, and was entered upon the minutes of the corporation or association. Name of Corporation or Association....................................................................................................... Date................................................ By........................................................................................ CORPORATE (Signature) SEAL* (.......).............................................. ........................................................................................... (Telephone Number) (Type Name and Title) *If the corporation does not have a seal, check here: q If association, check here: q NOTE: This revocation is effective 30 days after the date filed by the corporation or association with the Chairman, Workers Compensation Board and the insurance carrier. Section 54, Subdivision 6 of the New York Workers Compensation Law 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. Prescribed by Chairman C-105.53 (1-04) Workers Compensation Board State of New York www.wcb.state.ny.us