Specific Person Exclusion Form Page 2
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2MICHIGAN WORKERS COMPENSATION PLACEMENT FACILITY
**CERTIFIED RESOLUTION / CONSENT FORM**
CORPORATE BOARD RESOLUTION
(Complete this section if officers of a Corporation are being excluded)
I hereby certify that the following is a true copy of a resolution
duly
adopted
by
the
Board
of
Directors of
, a corporation duly organized and existing under the law of the
State of
, and that said resolution is in conformity with the Articles of Incorporation and By-laws of the
Corporation and is now in full force and effect.
WHEREAS, the named persons of
, elect to be excluded from the
corporation’s Workers Disability Compensation Insurance policy and further certify that each person listed on the
Specific Person Exclusion Form meets the requirements of Section 161 (4) of the Workers’ Disability Compensation
Act which states as follows:
“An employee who is subject to this act, including an employee of a corporation which has not more than ten (10)
stockholders and who is also an officer and stockholder who owns at least 10% of the stock of that corporation, with
the consent of the corporation as approved by its Board of Directors, may elect to be individually excluded from this
act by giving a notice of the election in writing to the carrier with the consent of the corporation endorsed on the
notice. The exclusion shall remain in effect until revoked by the employee by giving a notice in writing to the carrier.
While the exclusion is in effect, section 141 shall not apply to any action brought by the employee against the
corporation, and
WHEREAS, the filing of this exclusion shall also be consistent with the law of the State of Michigan.
In witness thereof,
I
have
hereunto
subscribed
my
name
and
attest
to
the
following
resolution
on this
day of
, 20
.
By:
Its:
(Corporate Title)
LIMITED LIABILITY COMPANY CONSENT
(Complete this section if members of a Limited Liability Company are being excluded)
The members listed on the Specific Persons Exclusion Form are also managers of
, a
limited liability company. The LLC has no more than 10 members and each member has at least a 10% interest in the LLC.
By majority vote of the members of the LLC, the members consent to the exclusion of its members from coverage afforded
pursuant to the Michigan Workers’ Disability Compensation Act.
It is understood and agreed that by signing this application for exclusion from coverage, I (we) elect to be excluded from all
benefits otherwise afforded under the Michigan Workers’ Disability Compensation Act pursuant to the Workers’ Compensation
and Employers Liability Policy.
On this
day of
, 20
.
By:
Member/Manager, certifying a majority
EDITION 01-06
vote of members
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