WORKERS’ COMPENSATION COMMISSION
INCLUSION FORM FOR SOLE PROPRIETORS/ PARTNERS ELECTION
Pursuant to the Workers’ Compensation Act, Annotated Code of Maryland, Labor and Employment Article,
§§ 9-219 and 9-227, sole proprietors and partners are excluded from coverage under the Act; however, such
persons may elect to become covered employees under the Act.
To exercise this option, any sole proprietor or partner electing to be a covered employee must complete and sign
Submit this form to the Workers’ Compensation Commission, a copy to the insurer, and keep a copy for your
Unless otherwise agreed, this election will be effective upon the date of receipt of this form by the MD
Workers’ Compensation Commission.
DATE INSURANCE COMPANY WAS NOTIFIED:
NAME OF INSURANCE COMPANY:
S T ATE:
Name and Title of Person Electing Coverage
FORM C-15R (Rev. 09/2019)
10 E. Baltimore Street Baltimore, MD 21202
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