07-6131 (Rev 1) ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers222 Compensation P.O. Box 115512 Juneau, AK 99811-5512 PETITION FOR EXECUTIVE OFFICER WAIVER Original Amendment Cancellation An executive officer of a business corporation (AS 10.06), a cooperative corporation (AS 10.15), an electric and telephone cooperative corporation (AS 10.25), or a professional corporation (AS 10.45) may waive their rights to benefits under the Alaska Workers222 Compensation Act (AS 23.30). To receive an Executive Officer Waiver, the following completed form and attachments must be submitted to the Division of Workers222 Compensation at the above address. 1.Legal Name of Corporation2. Federal Employer Identification No. 3.Entity Physical Address 4.Corporate Executive Officer(s) (Attach a separate sheet of paper if more space is needed) NameName Title(s)Title(s) Mailing Address Mailing Address NameName Title(s)Title(s) Mailing Address Mailing Address 5.Requestors Name6.Requestors Phone # 7.Requestors Email An executive officer means an employee of the corporation the president, vice-president, secretary, treasurer, or a corporate employee who is responsible for the corporation222s affairs generally, has a close connection to the board of directors and other officers, and who is specifically designated as an executive officer in the corporation222s articles and bylaws. To obtain an Executive Officer Waiver, a corporation must satisfy the following requirements a.Each officer must read and sign the Affidavit of Corporate Officers form. Each officer222s signature must be signed before a Notary Public. Be advisedthat the Alaska Corporate Code (AS 10.06) requires each corporation to have at least a President and Secretary. The office of the President and Secretary cannot be held by one individual, unless that person is the sole shareholder b.The corporation222s status must be active and in good standing with the Alaska Division of Corporations, Business, and Professional Licensing. If youare unsure of your corporate status, contact the licensing section at (907) 465-2534. c.The names of the executive officers contained in the petition must correlate with the listed officials found on the Alaska Division of Corporations,Business, and Professional Licensing website. d.The following must be included in this application. 225A copy of the first page of articles of incorporation and page(s) of the bylaws that state officer titles and duties225A copy of the minutes of the corporate meeting that reflects the election or appointment of the designated individuals as corporateexecutive officersAmending an existing Executive Officer Waiver: e.To add or change executive officers, a new petition must be submitted with an affidavit signed and notarized by each individual listed in thepetition. A copy of page(s) of minutes of corporate meeting that reflects the changes in corporate officers must be included. f.To remove an executive officer from a waiver, or cancel a waiver, the corporation must submit a written request to have the officer removed or thewaiver cancelled. The request must be signed by the person who was covered under the waiver, or by the president of the corporation. Please note: All documentation submitted is considered public information. Incomplete applications will be returned. American LegalNet, Inc. www.FormsWorkFlow.com 07-6131 (Rev 1/201) AFFIDAVIT OF CORPORATE OFFICERS Legal Name of Corporation I, , being first duly sworn, state I am a duly elected or appointed officer of the above named corporation. I request a waiver from coverage under the Alaska Workers222 Compensation Act. I am voluntarily, without coercion, signing this waiver request. I understand that I will not qualify for benefits in the event of a work related injury sustained during the performance of my duties as a corporate executive officer. I, , being first duly sworn, state I am a duly elected or appointed officer of the above named corporation. I request a waiver from coverage under the Alaska Workers222 Compensation Act. I am voluntarily, without coercion, signing this waiver request. I understand that I will not qualify for benefits in the event of a work related injury sustained during the performance of my duties as a corporate executive officer. Si g nature O f Officer Notar y Public in and for the State of Signature Of Officer Notary Public in and for the State of Si g nature of Notar y Public Subscribed to me this day of , My Commission Expires Si g nature of Notar y Public S ubscribed to me this day of , My Commission Expires I, , being first duly sworn, state I am a duly elected or appointed officer of the above named corporation. I request a waiver from coverage under the Alaska Workers222 Compensation Act. I am voluntarily, without coercion, signing this waiver request. I understand that I will not qualify for benefits in the event of a work related injury sustained during the performance of my duties as a corporate executive officer. I, , being first duly sworn, state I am a duly elected or appointed officer of the above named corporation. I request a waiver from coverage under the Alaska Workers222 Compensation Act. I am voluntarily, without coercion, signing this waiver request. I understand that I will not qualify for benefits in the event of a work related injury sustained during the performance of my duties as a corporate executive officer. Si g nature O f Officer Notar y Public in and for the State of Si g nature O f Officer Notar y Public in and for the State of Si g nature of Notar y Public Subscribed to me this day of , My Commission Expires Si g nature of Notar y Public Subscribed to me this day of , My Commission Expires American LegalNet, Inc. www.FormsWorkFlow.com