Fillable SOLE PROPRIETORS STATUS AS A COVERED EMPLOYEE FORM (Maryland Courts)

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SOLE PROPRIETORS STATUS AS A COVERED EMPLOYEE FORM (Maryland Courts)

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I hereby represent to the Maryland Workers’ Compensation Commission that I am a sole proprietor
doing
business in and about the State of Maryland, and that on the date set forth below my signature, under the
penalty of perjury, the following checked box represents my status as a covered employee.
Check one:
I have elected to become a covered employee under § 9-227 of the Labor and Employment
Article, Annotated Code of Maryland, and have submitted the requisite Inclusion form (IC-
15R) with the Workers’ Compensation Commission.
I
have not elected
to
become a covered employee under § 9-227 of the Labor and Employment
Article, Annotated Code of Maryland.
I UNDERSTAND THAT IF I HIRE ONE OR MORE EMPLOYEE(S), I MUST
OBTAIN WORKERS' COMPENSATION INSURANCE FOR THE EMPLOYEES
Name of Sole Proprietor
Address
Zip:
State:
City:
I affirm under the penalty of perjury, that the foregoing information is true to the best of my knowledge, information
and belief for the following period:
THROUGH .
(Effective date) (Expiration date)
Signature
Date
10 East Baltimore Street
Baltimore, Maryland 21202-1641
Form IC-02 (09/2019)
WORKERS' COMPENSATION COMMISSION
SOLE PROPRIETOR’S STATUS AS A COVERED EMPLOYEE FORM
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SOLE PROPRIETORS STATUS AS A COVERED EMPLOYEE FORM (Maryland Courts)

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Completed 14 June 2022

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