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
this document.
IMPORTANT:
Submit this form to the Workers’ Compensation Commission, a copy to the insurer, and keep a copy for your
records.
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:
CURRENT DATE:
NAME OF INSURANCE COMPANY:
COMPANY NAME:
ADDRESS:
CITY:
S T ATE:
ZIP:
Name and Title of Person Electing Coverage
Person
al Signature
FORM C-15R (Rev. 09/2019)
10 E. Baltimore Street Baltimore, MD 21202
CLICK HERE TO CLEAR THE FORM
