Election By Exempt Corporate Officer To Become Subject To Workers Compensation
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Election By Exempt Corporate Officer To Become Subject To Workers Compensation Form. This is a Rhode Island form and can be use in Department Of Labor And Training Workers Comp.
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Tags: Election By Exempt Corporate Officer To Become Subject To Workers Compensation, DWC-11C, Rhode Island Workers Comp, Department Of Labor And Training
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
State of Rhode Island, Department of Labor and Training, Workers’ Compensation Unit
:
P.O. Box 20190, Cranston, RI 02920-0942
Calendar No.
Phone (401) 462-8100 TDD (401) 462-8006
Plaintiff(s)
:
JUDICIAL SUBPOENA
ELECTION BY EXEMPT CORPORATE OFFICER TO BECOME SUBJECT TO WORKERS’ COMPENSATION
-against:
(TITLE 28 CHAPTERS 29 through 38)
:
* * * * THIS FORM ONLY APPLIES TO ANY PERSON WHO WAS APPOINTED A CORPORATE OFFICER
AND WAS NOT PREVIOUSLY AN EMPLOYEE OF THE CORPORATION
:
BETWEEN 1/1/1999 AND 12/31/2001 * * * *
I,
Defendant(s)
:
......................................................
Name
Soc. Sec. No.
THE PEOPLE OF THE STATE OF NEW YORK
Address
Date of Birth
TO
Corporate Title
GREETINGS:
an officer of the following business,
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
DBA
,
at the
Court
located at
County of
Address room
in
, on the
day of
, 20FEIN , 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
Name the Honorable
Insurer
Insurance Policy #
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
do hereby give notice in writing that I elect to become subject to the provisions of the Rhode Island Workers’
result of your failure to comply.
Compensation Statute (Title 28 Chapters 29 through 38).
, one my knowledge it is true, correct
Under penalties Witness, Honorable that I have examined this form and to the best of of the Justices of the
of perjury I declare
Court in
County,
day of
, 20
and complete. I further acknowledge that false statements on the within document may subject me to criminal
prosecution.
Signature _________________________________ Notary Public Signature __________________________
(Attorney must sign above and type name below)
Date _____________________________________ Date Commission Expires _________________________
Attorney(s) for
A filing fee of five dollars ($5.00) is required with the submission of this form. Please enclose a check or money order
payable to Rhode Island Department of Labor and Training. The employer should retain a copy of this form, send a
copy to the insurance company and send an original to the Department of Labor and Training. For a dated, receipt
copy, include a copy with the original sent to the Department of Labor and and P.O. Address
Office Training with a SELF-ADDRESSED,
STAMPED ENVELOPE. The original and copy will be date stamped. The original will be retained for our files. The
stamped copy will be returned in the envelope provided.
DWC-11-C (1/2002)
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
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