Cancellation of Elective Coverage for Excluded Employments State Fund Accounts Mail To: Employer Services PO Box 44140 Olympia WA 98504-4140 Fax 360-902-4633 Self-Insured Accounts Mail To: (Account ID starts with 700, 701, or 706) Self-Insurance PO Box 44891 Olympia WA 98504-4891 Fax 360-902-6860 The following categories of employment are not included within the mandatory coverage of the Industrial Insurance laws of Washington per Title 51 of the Revised Code of Washington. Please cancel coverage previously elected and indicated by checking the appropriate box(es). 1. 2. 3. Domestic servants Gardening, maintenance, repair, etc. in or about the employer's home Casual employment away from the employer's home and not associated with their business. Provide a brief description of the work being performed: Services in return for aid or sustenance only. Minor children under 18 years of age on a family farm. Jockey Racing Musicians and Entertainers Volunteer Law Enforcement Officer (Full Coverage) (6905) Volunteer Workers (Medical Aid only) Law Enforcement (6906) Other (6901) Community Improvement Project (6901) Student volunteers ­ public and private K ­ 12 and institutions of higher education (Medical Aid only 6901) Unpaid students in a work-based school-sponsored program (Medical Aid only 6901) Community Services (7203) Project Period: From: To: Newspaper carriers and freelance journalists Insurance producers or surplus line brokers 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. I, the undersigned, certify that I am authorized to execute this Cancellation for Elective Coverage on behalf of this business, public entity, or nonprofit organization. Benefits in accordance with Title 51 RCW are to be provided to all persons, now or hereafter working under this optional coverage until 30 days after written notice of cancellation of this election has been received by the department. I shall post notice of this cancellation at least 30 days before the effective date in the work area of the affected worker(s) and shall personally notify other affected worker(s). (RCW 51.12.110) This cancellation will be not become effective prior to such time as the Department of Labor and Industries receives this signed notification. Business Name Business Address Applicant's Name Applicant's Phone Number Date UBI City Official Position Applicant's Email Address Signature Account ID State Zip Code F213-005-000 Cancellation of Elective Coverage for Excluded Employments 05-2016 American LegalNet, Inc. www.FormsWorkFlow.com