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New Mexico Executive Employee Affirmative Election Form (Exemption From WC Coverage) Form. This is a New Mexico form and can be use in Workers Compensation.
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Tags: New Mexico Executive Employee Affirmative Election Form (Exemption From WC Coverage), New Mexico Workers Compensation,
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
Index No.
Calendar No.
:
STATE OF NEW MEXICO JUDICIAL SUBPOENA
Plaintiff(s)
WORKERS’ COMPENSATION ADMINISTRATION
-against-
:
:
NEW MEXICO EXECUTIVE EMPLOYEE
:
AFFIRMATIVE ELECTION FORM
Defendant(s)
:
......................................................
I, _______________________________, am a “worker” as defined in the New Mexico Workers’
THE PEOPLE OF THE STATE OF NEW YORK
NAME
Compensation Act, §52-1-1, et seq. or the New Mexico Occupational Disease Disablement Law,
TO
§52-3-1, et seq. (the Acts). I am employed by _________________________, a Corporation
NAME OF CORPORATION
subject to the provisions of one or both of the Acts. Pursuant to § 52-1-7 or § 52-3-6 of the Acts,
GREETINGS:
I AFFIRMATIVELY ELECT NOT TO ACCEPT THE PROVISIONS OF THE WORKERS’
COMPENSATION ACTYOU, that NEW MEXICOexcuses being laid aside, you andDISABLEMENT before
WE COMMAND OR THE all business and OCCUPATIONAL DISEASE each of you attend
LAW. I meet
§ 52-3-6 as follows:
,
the Honorable the qualifications of § 52-1-7 orat the
Court
located at
County of
in§I am the chairperson of the board, president, vice at
room
, on the
day of
, 20
, president, secretary or treasurer or other
o'clock in the
noon, and at any recessed
orexecutive officer of employer Corporation; and
adjourned date, to testify and give evidence as a witness in this action on the part of the
§ own ten percent or more of the outstanding stock of employer Corporation.
I
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
I party on whose by accepting this Affirmative Election, it applies to all of $50 and all which I have
the understand that behalf this subpoena was issued for a maximum penalty corporations indamages sustained as a
a financial failure further
result of yourinterest.toI comply. 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’ Office, and to mail a copy
s
of the revocationHonorable
I further Justices notify
Witness, to the board of directors of employer Corporation(s)., one of theagree to of the the
WCA
s County,
Court in Director’ Office of any changes in my § 52-1-7 or § 52-3-6 status.
day of
, 20
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
(Attorney must sign above and type name below)
knowledge.
Signature:_________________________________
Executive Title:____________________________
UI Number ______________
Attorney(s) for
FE ID Number ___________
Office and P.O. Address
WC/CB A-I (06/98)
mjd/inet page 1 of 2
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Plaintiff(s)
STATE OF
-against-
)
)
)
COUNTY OF
Calendar No.
:
JUDICIAL SUBPOENA
:
ss.
:
:
The foregoing instrument was subscribed and sworn to before me this _____ day of
Defendant(s)
__________________, 20__.
:
......................................................
___________________________________
______________________________
My Commission Expires
THE PEOPLE OF THE STATE OF NEW YORK
Notary Public
TO
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
WC/CB A-I (06/98)
mjd/inet page 2 of 2
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
