State of New York
WORKERS' COMPENSATION BOARD
NOTICE OF ELECTION OF A CORPORATION WHICH IS REQUIRED TO HAVE COVERAGE FOR ITS
EMPLOYEES UNDER THE NEW YORK STATE WORKERS' COMPENSATION LAW TO EXCLUDE THE
SOLE SHAREHOLDER-OFFICER OR ONE OF THE TWO OR BOTH EXECUTIVE
OFFICERS-SHAREHOLDERS OF THE CORPORATION FROM SUCH COVERAGE
TAKE NOTICE that under the provisions of Section 54, subdivision 6, of the Workers' Compensation Law as amended, the
corporation named below elects to exclude the executive officer(s) named below from coverage under the New York State
Workers' Compensation Law with respect to all the policies issued to the corporation by the insurance carrier named above.
Name of Corporation _____________________________________________________________________________________
Address of Corporation ___________________________________________________________________________________
Incorporated Under the Laws of the State of __________________________________________________________________
Type: One-person corp. Two-person corp. (A two-person corporation may elect to exclude one or both executive
officers, provided that between them they own all the stock in the corporation, and that each officer owns at least one share of
stock.)
ExecutiveOfficer(s) 1. Name _________________________________ Title ___________________________________
to be Excluded from
Policy 2. Name__________________________________ Title ___________________________________
To: (Print name and address of insurance carrier here.)
USE FOR ONE-PERSON CORPORATION
I, ___________________________________, certify that I am the sole executive officer of the above-named corporation; that I
have been since _______________the sole owner of all issued and outstanding stock of the corporation and hold all the offices
pursuant to paragraph (e) of Section 715 of the Business Corporation Law. (Affix corporate seal below, if you have one.)
____________________________________________ ___________________________ _____________________________
Signature of Officer Date Telephone No.
CERTIFICATION
USE FOR TWO-PERSON CORPORATION
We, _____________________________ , ________________________________ and _______________________________,
_____________________________ certify that we are the two executive officers of the above-named corporation, having been
duly appointed by corporate resolution; that we have been since ______________ the sole owners of all issued and outstanding
stock and that each of us owns at least one share of stock of the corporation, and that we hold all of the offices pursuant to
paragraph (e) of Section 715 of the Business Corporation Law. (Affix corporate seal below, if you have one.)
_____________________________________________ __________________________ ______________________________
Signature of Officer Date Telephone No.
_______________________________________________________ __________________________________ _______________________________________
Signature of Officer Date Telephone No.
THIS ELECTION IS FINAL AND BINDING
UPON THE OFFICER(S) NAMED UNTIL
REVOKED BY THE CORPORATION.
See reverse side for relevant portions of Sec. 54, subd. 6 (WCL)
and Sec. 715, Par. (e) of the Business Corporation Law.
C-105.51 (1-04)
Title
Date
Date
TitleName Name
Name
www.wcb.ny.gov
*If the corporation does not
have a seal, check here q
CORPORATE
SEAL*
(Print Name and Address of Insurance Carrier Here)
