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) _______________________________________________________. (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. ______________________________________ Signature _______________________ Date UI Number: ___________________________ FEIN Number: __________________________ STATE OF ______________________ ) ) ss. COUNTY OF ____________________ ) SUBSCRIBED AND SWORN to before me on the _______ day of ______________, 20__________ by ______________________________________. ________________________________ Notary Public My commission expires: ____________________ WC/ECB A-V (9/08) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com