Election To Refuse
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Election To Refuse Form. This is a New Mexico form and can be use in Workers Compensation.
Tags: Election To Refuse, New Mexico Workers Compensation,
STATE OF NEW MEXICO
WORKERS’ COMPENSATION ADMINISTRATION
ELECTION TO REFUSE THE COVERAGE OF THE
WORKERS’ COMPENSATION ACT AND
OCCUPATIONAL DISEASE AND DISABLEMENT LAW
PLEASE TYPE OR LEGIBLY PRINT ALL ENTRIES EXCEPT SIGNATURE.
I, ______________________________________________________________, am the sole-proprietor of
(Name of business)
I own all the assets of my business.
I am liable for the debts of my business.
I understand that if my business is engaged in activities subject to the licensing requirements of
the Construction Industries Licensing Act, I am required to buy insurance even if I am the only
worker in the business.
I understand that this election applies only to myself as a worker in my business.
CHECK ONE: ( ) No one works for me in my business OR
( ) I employ workers other than myself in my business.
I choose to have NO coverage for myself under the Workers’ Compensation Act and Occupational
Disease and Disablement Law.
UI Number: ___________________________
FEIN Number: __________________________
STATE OF ______________________ )
COUNTY OF ____________________ )
SUBSCRIBED AND SWORN to before me on the _______ day of ______________,
20__________ by ______________________________________.
My commission expires:
WC/ECB A-V (9/08)
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