Specific Person Exclusion Form printable pdf download

Specific Person Exclusion Form

MICHIGAN WORKERS COMPENSATION PLACEMENT FACILITY

SPECIFIC PERSON EXCLUSION FORM

NAME OF ENTITY:

FEIN:

LEGAL FORM OF ENTITY:

Sole Proprietor

Partnership

Corporation

Limited Liability Company

PERSONS ELIGIBLE FOR EXCLUSION BY LEGAL ENTITY

Sole Proprietor

Spouse, Child, Parent

Partnership

Partner

Corporation

Executive Officers may elect exclusion if the corporation has ten or fewer stockholders and the

executive officer owns at least 10% of the stock. A corporate board resolution authorizing

exclusion is to be executed.

(Certified Resolution/Consent Form must also be completed.)

Limited Liability

Member/Managers of a limited liability company may elect exclusion if the LLC has ten or fewer

Company

members and the member is also a manager who owns at least a 10% interest. Exclusion must

be approved by majority vote of members or if more than 1 manager, all managers who are also

members.

(Certified Resolution/Consent Form must also be completed.)

Title or

% of Stock

Name

Relationship

Owned

Signature

Date

It is understood and agreed that I (we), whose signature(s) appear above, wish to be excluded from all benefits normally

provided on the Workers Compensation and Employers Liability Policy. This is to apply to current and renewal policies.

THIS FORM NOT VALID UNLESS COMPLETELY FILLED OUT

EDITION 01-04

Specific Person Exclusion Form