Notice Of Election Or Rejection Of Workers Compensation Coverage

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GEORGIA STATE BOARD OF WORKERS' COMPENSATION
NOTICE OF ELECTION OR REJECTION
OF WORKERS' COMPENSATION COVERAGE
The use of this form is required under the provisions of: (A) O.C.G.A. ! 34-9-2.1 of the Workers' Compensation Law if a
corporate officer or limited liability company member elects to reject coverage; (B) O.C.G.A. ! 34-9-2.2 if a sole proprietor
or partner elects to be included as an employee; or, (C) ! 34-9-2.3 if a farm labor employer elects to provide coverage for
farm laborers.
A. CORPORATION/LIMITED LIABILITY COMPANY
I,
, certify I am an officer/member of
(Employer).
(Print or Type)
(Street Address)
Office Held
(City/State/Zip)
I elect to reject the provisions of the Georgia Workers' Compensation Law.
I elect to revoke the previous rejection of
.
(DATE)
(NOTE: A maximum of five (5) officers/members may be exempted)
B. SOLE PROPRIETOR OR PARTNER
I,
, certify that I am a Sole Proprietor
Partner
of
(business name).
I elect to be covered under the provisions of the Georgia Workers' Compensation Law.
I elect to revoke the previous election of
.
(DATE)
C. FARM LABOR
I,
, certify that as the employer or representative of
(business name), that
I elect to provide Workers' Compensation coverage for farm laborers.
I elect to revoke the previous election of
.
(DATE)
D. CERTIFICATION
I hereby certify that the information listed is true and correct:
(
)
Print Name
Business Phone Number
Extension
Dated this
day of
/
.
Business Address
Signed
A COPY OF THIS FORM MUST BE FILED WITH YOUR CURRENT WORKERS' COMPENSATION CARRIER. IF YOU DO NOT HAVE A
CARRIER, THIS FORM MUST BE FILED WITH THE STATE BOARD OF WORKERS' COMPENSATION AT 270 PEACHTREE STREET, N.W.,
ATLANTA, GEORGIA 30303-1299. NOTE: DO NOT SEND TO THE BOARD IF THERE IS INSURANCE COVERAGE.
Willfully making a false statement for the purpose of obtaining or denying benefits is a crime subject to penalties of up to $10,000.00 per violation (O.C.G.A. ! 34-9-18 and ! 34-9-19).
N
E
R
OTICE OF
LECTION OR
EJECTION
10
F
WC-10
R
. D
7/99
W
' C
C
ORM
EV
ATE
OF
ORKERS
OMPENSATION
OVERAGE

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