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New Mexico Limited Liability Company Member 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 Limited Liability Company Member 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 LIMITED LIABILITY COMPANY MEMBER
:
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 New
LIMITED LIABILITY COMPANY
Mexico Limited Liability Company subject to the provisions of one or both of the Acts. Pursuant to
GREETINGS:
§52-1-7 or §52-3-6 of the Acts, I AFFIRMATIVELY ELECT NOT TO ACCEPT THE
PROVISIONS OF THE WORKERS’ COMPENSATION ACTaside, you andNEWofMEXICO before
WE COMMAND YOU, that all business and excuses being laid OR THE each you attend
OCCUPATIONAL DISEASE DISABLEMENTthe
,
the Honorable
at LAW. I meet the qualifications of § 52-1-7 or
Court
§ 52-3-6
located at
County of as follows:
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or§ am a member of employer Limited Liabilitywitness in this action on the part of the
adjourned date, to testify and give evidence as a Company; and
I
§I own a ten percent or more interest, pursuant to §53-19-20, in employer Limited Liability
Company. failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
Your
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
I understand that to comply.
result of your failureby accepting 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 one of the Justices thethe
Witness, Honorable
, carrier and with of WCA
Director’
Court in s Office, and to mail a copy of the revocation to the board of directors of the Corporation.
County,
day of
, 20
I further agree to notify the WCA Director’ Office of any changes in my § 52-1-7 or § 52-3-6
s
status.
(Attorney must sign above and type name below)
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.
Attorney(s) for
Signature:_________________________________
Executive Title:____________________________
WC/CB A-IV (06/98)
mjd/inet page 1 of 2
UI Number ______________
FE ID Number ___________
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Plaintiff(s)
-against-
Calendar No.
:
JUDICIAL SUBPOENA
:
STATE OF
:
)
) ss.
)
COUNTY OF
:
Defendant(s)
:
......................................................
The foregoing instrument was subscribed and sworn to before me this _____ day of
__________________, 20__.
THE PEOPLE OF THE STATE OF NEW YORK
___________________________________
______________________________
My Commission Expires
TO
Notary Public
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-IV (06/98)
mjd/inet page 2 of 2
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
