SF0137 1/16 Minnesota Department of Labor and Industry SCF P.O. Box 64229 St. Paul, MN 55164-0229 Election to Exclude Certain Relatives of Managers of a Limited Liability Company Minnesota Statutes 247 176.041, subd. 1(20) Use this ithin the third degree of kindred to a manager of a limited liability company (LLC) who owns at least 25 percent membership in the LLC. A manager of the LLC 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 a manager who owns at least a 25 percent membership in the LLC they are automatically excluded from coverage. Section 1. Information about the limited liability company Legal name of the LLC exactly as registered with the Minnesota Secretary of State Phone number Mailing address City State ZIP code Section 2. Eligibility A. Is this LLC owned by 10 or fewer members? Yes No B. Did this LLC have less than 22,880 hours of payroll in the preceding calendar year? Yes No C. Is this LLC currently registered as active with the Minnesota Secretary of State? Yes No parent covered. Section 3. Membership interest owned by the manager(s) of the LLC List the names of all managers who own at least 25 percent membership interest in the LLC Percent of the LLC membership interest owned by this manager (over) American LegalNet, Inc. www.FormsWorkFlow.com SF0137 1/16 Section 4. Relatives to be excluded from List the relatives to be managers listed in Section 3. (Attach an additional sheet if necessary.) Name of the relative to be excluded Name of the related LLC manager Relationship to the manager 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 LLC named in Section 1. Phone number Signature Date signed 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 still 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) 215 - 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 manager 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 LLC or manager(s) injuries of the relatives listed in 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