www.labor.vermont.gov State of Vermont Department of Labor PO Box 488 Montpelier, VT 05601-0488 (802) 828-2286 Form 29 ­ Rev. 2/13 Application To Exclude Corporate Officers or LLC Members From Workers' Compensation Coverage Officer/Member Exclusion. Vermont law permits corporate officers or LLC members to exclude up to four (4) officers or members from protection under the Vermont Workers' Compensation Act. Corporate officer refers to the President, Vice President, Secretary of the Corporation, Clerk or Treasurer. A Limited Liability Company may exclude up to four (4) managers or members. Corporation/LLC Exclusion. Vermont law permits a corporation or LLC to be wholly excluded from workers' compensation coverage requirements when all of the corporate officers or members are excluded and the corporation or LLC has no workers. 1 Legal Name of Corporation/LLC: Federal ID Number: Business Name (if different): Address of Corporation/LLC: (Street, Rural Route, Box Number) (City/Town, State and Zip Code) You must attach a NOTARIZED copy of the minutes of the Board of Directors meeting. 1. 2. Attach minutes indicating that the applicant has been elected an officer of the company. The minutes must indicate that the directors have approved the exclusion. The undersigned, an officer of the above-named corporation or member of the LLC, elects to be excluded from coverage under the corporation's/LLC's workers' compensation policy, and not be entitled to the protections provided by Vermont Workers' Compensation Act from the date this application is approved by the Commissioner. Name of Officer/Member (Print or Type) Signature of Officer/Member Position Held in Corporation/LLC Date Signed Note The records on file in the Secretary of State's office must indicate that the above business is presently incorporated or an LLC and that its charter has not been revoked. It is your responsibility to provide the information we need in order for us to approve this application in a timely manner. Exclusions, if approved, may take effect no earlier than the date upon which the Commissioner received a COMPLETE application and the required minutes. Please complete the form and return to the Department of Labor, PO Box 488, Montpelier, VT 05601-0488. After approval, two copies will be returned to you, one for your corporate files and one for submission to the insurance agent. ______________________________________________ Approved _____________________________________________ Commissioner of Labor or Designee 1 For corporation/LLC exclusion you must attach a Form 29 for each corporate officer/member. American LegalNet, Inc. www.FormsWorkFlow.com