CORPORATE OFFICER EXCLUSION _____________________________________________________________________ PRINT NAME OF CORPORATION/LLC PHYSICAL ADDRESS _____________________________________________________________________ MAILING ADDRESS _____________________________________________________________________ CITY STATE ZIP ( )____________________________ TELEPHONE I, the undersigned officer of the above named corporation, do hereby, elect to be exempt from coverage under the Alabama Workers= Compensation Law, 25-5-50(b) Code of Alabama,1975, as amended. Name of Officer_________________________Title__________________Date______________ (Print or Type Name & Title) _________________________________________ I, the undersigned officer of the above named corporation, do hereby, elect to be exempt from coverage under the Alabama Workers’ Compensation Law, 25-5-50(b) Code of Alabama 1975, as amended. Under penalty of perjury, I hereby certify that I am a duly appointed officer of the above captioned corporation. I further certify and affirm that all statements contained herein are true and correct. NUMBER OF EMPLOYEES (FULL & PART-TIME)____________________________ FEDERAL ID NUMBER__________________________________________________ UNEMPLOYMENTNUMBER______________________________________________ WC INSURANCE CARRIER______________________________________________ POLICY NUMBER _____________________________________________________ EFFECTIVE DATES____________________________________________________ INSURANCE AGENCY________________________TELEPHONE ( )___________ WE ONLY ACCEPT ORIGINAL SIGNATURES EMPLOYERS NOTICE TO COVER HIMSELF/EMPLOYEES American LegalNet, Inc. www.USCourtForms.com MARK ALL THAT APPLY: Part I Per Article 3, 25-5-50(a), Code of Alabama, an employer who regularly employs less than five employees in any one business; a farm-labor employee; an employer of a domestic employee; or a municipality having a population of less than 2,000 according to the most recent federal decennial census, may accept and become subject to this article and Article 4 of this chapter by filing written notice thereof with the Department of Industrial Relations. ( ) In accordance with the Code of Alabama, I elect my business to be covered by the Workers’ Compensation Laws of the State of Alabama. Part II Per Article 3, 25-5-50(a), Code of Alabama, may at any time withdraw the acceptance by giving like notice of withdrawal. Notwithstanding the foregoing, an employer electing not to accept coverage under this article and Article 4 of this chapter shall notify in writing each employee of the withdrawal of coverage. Additionally, the employer shall post a notice in a conspicuous place notifying all employees and applicants for employment that workers’ compensation insurance coverage is not available. In accordance with the Code of Alabama ( ) Having previously been subject to the Workers’ Compensation Laws, I choose to withdraw my business from coverage pursuant to the bove cited code section. ( ) I hereby certify that I have notified my employees of my election to withdraw and have posted a notice in a conspicuous place notifying employees and applicants of employment that workers’ compensation is not available. Part III ( ) Having previously been excluded as an officer or member, I choose to be included pursuant to the above cited code. INFORMATION MUST BE PRINTED BUSINESS NAME DATE____________ Mailing Address_____________________________Physical Location______________ City____________________State_________Zip_________Telephone ( )__________ Print Name and Title____________________________________________________ SIGNATURE___________________________________________________________ Sole-Proprietor/Partnership/ Officer/Member FEIN___________________________UC NUMBER___________________________ WC INSURANCE CARRIER__________________EFFECTIVE____________POLICY #_____________ THIS DIVISION WILL ONLY ACCEPT ORIGINAL SIGNATURES American LegalNet, Inc. www.USCourtForms.com