STATE OF NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION LIMITED LIABILITY COMPANY MEMBER AFFIRMATIVE ELECTION PLEASE TYPE OR LEGIBLY PRINT ALL ENTRIES EXCEPT SIGNATURE. I, ________________________________ (Name), am a “worker” as defined in the New Mexico Workers’ Compensation Act or the New Mexico Occupational Disease Disablement Law (“the Acts”). I am employed by ______________________________ (Name of Limited Liability Company), a new Mexico limited liability company subject to the provisions of one or both of the Acts. Pursuant to §52-17 or §52-3-6, I affirmatively elect NOT TO ACCEPT the provisions of the Workers’ Compensation Act or the New Mexico Occupational Disease Disablement Law. I meet the qualification of §52-1-7 or §523-6 as follows: ▪ I am a member of employer Limited Liability Company; and ▪ I own a ten percent or more interest in employer Limited Liability Company pursuant to NMSA 1978, §53-19-20. I understand that by making this affirmative election, it applies to all New Mexico limited liability companies in which I have a financial interest. I further understand that if I wish to revoke my election, I am required by law to file a revocation with my insurance carrier and with the WCA Director’s Office, and to mail a copy of the revocation to the board of directors of the limited liability company. I further agree to notify the WCA Director’s Office of any changes in my §52-1-7 or §52-3-6 status. I swear or affirm under penalty of perjury that I have read the foregoing affirmative election in its entirety and understand the information contained therein is true and correct to the best of my knowledge. Signature: ________________________________ UI Number: _______________________ Executive Title: ___________________________ 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-IV (09/08) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com