South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 (803) 737-6203 The completed Form 5 must be filed with your insurance carrier, not with the S.C. Workers' Compensation Commission. CORPORATE OFFICER NOTICE TO REJECT To the Employer of the Undersigned and the Employer's Insurance Carrier: The undersigned officer rejects the terms, conditions, and provisions of the South Carolina Workers' Compensation Act and elects to pursue compensation for personal injuries under the common law and statutes of South Carolina. As provided by law (Section 42-1-520), "An officer of a corporation who elects not to operate under this title shall, in any action to recover damages for personal injury or death brought against an employer accepting the compensation provisions of this title, proceed at common law and the employer may avail himself of the defenses of contributory negligence, negligence of a fellow servant, and assumption of risk, as such defenses exist at common law." This notice becomes effective on the date listed below, no sooner than the day following the date signed by the corporate officer. ** PLEASE PRINT OR TYPE ALL INFORMATION ** ORIGINAL SIGNATURES REQUIRED ** Name of Officer Street Address City Social Security Number Area Code Signature of Officer Subscribed and sworn to me this Corporate Title P.O. Box State Zip Name of Business (Legal Name) Street Address City P.O. Box State Zip Federal Employer ID # Telephone Number Date day of , . Area Code Effective Date Telephone Number My Commission Expires: Notary Public This form may be used when an officer desires to become exempt from the provisions of the South Carolina Workers' Compensation Act. For additional information regarding the provision of Section 42-1-520 and this form, contact your insurance carrier or the South Carolina Workers' Compensation Commission, Coverage Division, Post Office Box 1715, Columbia, South Carolina 29202-1715. (803) 737-6203. WCC Form # 5 Rev. 05/2013 5 Corporate Officer Notice to Reject American LegalNet, Inc. www.FormsWorkFlow.com