SF0138 1/16 Minnesota Department of Labor and Industry SCF P.O. Box 64229 St. Paul, MN 55164-0229 Election to Exclude Certain Relatives of Executive Officers of a Closely Held Corporation Minnesota Statutes 247 176.041, subd. 1(15) Use this oyees who are related within the third degree of kindred to an executive officer who owns at least 25 percent of the stock of a closely held corporation. An executive officer of the corporation must complete and sign this form. A chart showing relatives within the third degree of kindred is online at www.dli.mn.gov/sites/default/files/pdf/infosheet3rddegreekindred.pdf . You do not need to file this form if you only intend to exclude the spouse, parent or children of an executive officer who owns at least 25 percent of the stock of the corporation they are automatically excluded from coverage. Section 1. Information about the closely held corporation Legal name of the corporation exactly as registered with the Minnesota Secretary of State Phone number Mailing address City State ZIP code Section 2. Eligibility A. Is the stock of this corporation owned by 10 or fewer persons? Yes No B. Did this corporation have less than 22,880 hours of payroll in the preceding calendar year? Yes No C. Is this corporation currently registered as active with the Minnesota Secretary of State? Yes No If you are not eligible to exclude relatives other than the spouse, parent or children of the executive officer sure they are covered. If you answered Section 3. Stock owned by the executive officers List the names of all executive officers who own at least 25 percent of stock in the corporation Title of executive officer owned by this executive officer (over) American LegalNet, Inc. www.FormsWorkFlow.com SF0138 1/16 List the relatives to be executive officers listed in Section 3. (Attach an additional sheet if necessary.) Name of the relative to be excluded Name of the related executive officer Relationship to the executive officer Section 5. Certification By signing this form I certify that all information provided is complete and accurate to the best of my knowledge and that I have the authority to sign this form for the closely held corpor ation named in Section 1. name (print or type ) Signature Date s igned Phone number Have the relatives listed in Section 4 been notified that this form to exclude them n coverage is being filed? Yes No Submit a copy of this form to your workers' compensation insurance company, if any. If you change insurance companies, submit a copy of this form to the new insurance company. urer if any information in Sections 2, 3 or 4 changes and you File a copy of this form with the Department of Labor and Industry. In p erson By m ai l By f ax Department of Labor and Industry Department of Labor and Industry (651) 2 15 - 9099 Special Compensation Fund Special Compensation Fund 443 Lafayette Road N. P . O . Box 64229 St. Paul, MN 55155 St. Paul, MN 55164 - 0229 Notice The election to exclude relatives from workers' compensation coverage is not effective unless this form has been filed with DLI. If the information provided on this form is accurate and meets the statutory requirements, the effective date of this exclusion will be based on the date DLI receives this form. DLI does not guarantee that this election to exclude the relatives listed in Section 4 from workers' compensation coverage is legally effective. The executive officer signing this form is responsible for determining the legal obligations and for correctly and accurately completing this form. DLI will notify you of potential defects if they are apparent, but you are encouraged to consult an attorney about the legal effect of this election. If the information provided is not accurate and complete, or the information changes, the corporation or executive officers may be Section 4. The information you provide on this form may be available to the public upon request. This document can be given to you in Braille, large print or audio by calling (651) 284-5019 or 1-800-342-5354. Questions? Contact Dave Horning at (651) 284-5422 or dave.horning@state.mn.us. American LegalNet, Inc. www.FormsWorkFlow.com