South Carolina Workers' Compensation Commission 1333 Main Street, Suite 500 P.O. BOX 1715 Columbia, SC 29202-1715 803-737-5708 EMPLOYER'S WITHDRAWAL OF ELECTION TO ADOPT THE SOUTH CAROLINA WORKERS' COMPENSATION ACT This form is required if an employer who elected to adopt the Workers' Compensation Act, being previously exempt as prescribed in Section 42-1-360 of the Act, now desires to withdraw its election. Date: To the South Carolina Workers' Compensation Commission: The undersigned employer, who has voluntarily elected to operate under the South Carolina Workers' Compensation Act, being previously exempt as prescribed under Section 42-1-360 of the Act, withdraws that election to operate under the Workers' Compensation Act. As provided by law (Section 42-1-390), the employer must give notice in writing to the Commission that the business shall no longer operate under the S.C. Workers' Compensation Act. This rejection takes effect sixty (60) days after the date it is received by the South Carolina Workers' Compensation Commission. , . * * PLEASE PRINT OR TYPE ALL INFORMATION * * ORIGINAL SIGNATURES REQUIRED * * SWORN TO AND SUBSCRIBED BEFORE ME at EMPLOYER Name of Business (Legal Name) this of , Federal I.D. # Street Address Post Office Box State Zip Code Notary Public for South Carolina City By: My Commission Expires: For Official Use Only: Name and Title Date Received: Effective Date: Approved By: Telephone Number: Area Code Telephone Number Signature of Employer Official Date Reference Summary: Sections 42-1-310, 42-1-380, and 42-1-390. For more information about the provisions of these Sections and this form, please contact the Commission at the address above. WCC Form # 38 Rev. 1/88 38 EMPLOYER'S WITHDRAWAL OF ELECTION TO ADOPT THE SOUTH CAROLINA WORKERS' COMPENSATION ACT American LegalNet, Inc. www.FormsWorkFlow.com