SOLE PROPRIETOR COVERAGE Pursuant to NRS 616B.659 Sole Proprietor Name: Business Name: Business Address: Telephone Number: Federal Identification Number: NOTICE OF ELECTION OF COVERAGE Sole Proprietor Signature: Effective Date: NOTICE OF WITHDRAWAL OF ELECTED COVERAGE Sole Proprietor Signature: Effective Date: NOTICE TO PAY ADDITIONAL PREMIUMS FOR ADDITIONAL COVERAGE Sole Proprietor Signature: Effective Date: Date Notice to Administrator: Date Notice to System: Date Notice to Insurer: FOR WCS USE ONLY Method of Transmission First Class Mail [ ] Electronic Transmission/Fax [ ] Personally Served [ ] Date Notice Received: D-45 (Rev. 02/04)