Revocation (Of Election To Accept WC Coverage Or Affirmative Election Of Exemption From WC Coverage)
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Revocation (Of Election To Accept WC Coverage Or Affirmative Election Of Exemption From WC Coverage) Form. This is a New Mexico form and can be use in Workers Compensation.
Loading PDF...
Tags: Revocation (Of Election To Accept WC Coverage Or Affirmative Election Of Exemption From WC Coverage), New Mexico Workers Compensation,
STATE OF NEW MEXICO
WORKERS’ COMPENSATION ADMINISTRATION
REVOCATION
PLEASE TYPE OR LEGIBLY PRINT ALL ENTRIES EXCEPT SIGNATURE.
RE: ___________________________________________________________________
( ) Corporation
( ) Partnership
( ) Sole Proprietorship ( ) Limited Liability Company
You are notified that the undersigned hereby waive(s) and revoke(s) previously filed forms, as checked
below: (check one)
( )
Executive Employee Affirmative Election, Form WC/ECB A-I (NMSA 1978, §52-1-7)
( )
Limited Liability Company Member Affirmative Election, Form WC/ECB A-IV (NMSA
1978, §52-1-7)
( )
Election to Accept, Form WC/ECB A-II (NMSA 1978, §52-1-6)
( )
Election to Refuse the Coverage of Workers’ Compensation Act WC/ECB A-V (NMSA
1978, §52-1-7)
UI Number: _________________________
FEIN Number: __________________________
Revocation is specifically provided by NMSA 1978, §52-1-7. The undersigned acknowledges acceptance
of the terms, conditions, and provisions of the New Mexico Workers’ Compensation Act and New
Mexico Occupational Disease and Disablement Law.
Type or print clearly the name and title of each officer or owner under the signature.
Signature:
___________________________________________________
Name and Title: ___________________________________________________
Signature:
___________________________________________________
Name and Title: ___________________________________________________
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-III (09/08)
Page 1 of 1
American LegalNet, Inc.
www.FormsWorkFlow.com
