Election To Accept (Employers Election To Accept WC Coverage)
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Election To Accept (Employers Election To Accept WC Coverage) Form. This is a New Mexico form and can be use in Workers Compensation.
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Tags: Election To Accept (Employers Election To Accept WC Coverage), New Mexico Workers Compensation,
STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION ELECTION TO ACCEPT PLEASE TYPE OR LEGIBLY PRINT ALL ENTRIES EXEPT SIGNATURE. This is to certify that I, _______________________________, of ________________________, (Name of Business/DBA(s)) am an employer in the State of New Mexico, who, pursuant to NMSA 1978, §52-1-6, ACCEPTS the provisions of the New Mexico Workers' Compensation Act and Occupational Disease Disablement Law. I hereby elect to be included in the definition of employer and employee for the purpose of entitlement to the benefits under the law. Signature: ______________________________________ Title: __________________________________________ Date: _____________________ Unemployment Insurance Number: ___________________________ Federal Employer Identification Number: __________________________ ) ) ss. COUNTY OF ____________________ ) SUBSCRIBED AND SWORN to before me on the _______ day of ______________, 20__________ by ____________________________________________. STATE OF ___________________ ________________________________ Notary Public My commission expires: ____________________ WC/ECB A-II (9/08) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com
