Limited Liability Company Member Affirmative Election
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Limited Liability Company Member Affirmative Election Form. This is a New Mexico form and can be use in Workers Compensation.
Tags: Limited Liability Company Member Affirmative Election, New Mexico Workers Compensation,
STATE OF NEW MEXICO
WORKERS’ COMPENSATION ADMINISTRATION
LIMITED LIABILITY COMPANY MEMBER
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,
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.
UI Number: _______________________
Executive Title: ___________________________
FEIN Number: ____________________
STATE OF ______________________ )
COUNTY OF ____________________ )
SUBSCRIBED AND SWORN to before me on the _______ day of ______________,
20__________ by ____________________________________________.
My commission expires:
WC/ECB A-IV (09/08)
Page 1 of 1
American LegalNet, Inc.