Pp-1a - Notice Of Election Of Liability Insurance
ADVERTISEMENT
1FORM PP-1 A
NEW JERSEY
NOTICE OF ELECTION - PROPRIETORS AND PARTNERS
WORKERS’ COMPENSATION AND EMPLOYERS’ LIABILITY INSURANCE
The New Jersey Workers’ Compensation Law was amended effective April 13, 2000. The amendment permits
election by a self-employed person or partners of any partnership including partners of a limited liability
partnership and members of a limited liability company actively performing services on behalf of the business to
be deemed employees for the purpose of receipt of benefits and the payment of premiums. This election does not
affect the insurance obligations for employees other than the self-employed person, partners or members.
The election must be made at the time the policy is purchased or renewed and must be effective at the inception
date of the policy. It is important to note that the election cannot be rescinded during the policy period and that in
the case of any partnership including a limited liability partnership or limited liability company, ALL of the partners
or ALL of the members must elect the coverage. You will be required to pay a premium based on the
remuneration and duties of the self-employed person or each partner or each member.
The insurer or insurance producer shall not be liable in an action for damages on account of the failure of a
business, limited liability partnership, limited liability company or partnership to elect to obtain workers’
compensation coverage for a self-employed person, limited liability partner, limited liability company member or
partner, unless the insurer or insurance producer causes damage by a willful, wanton or grossly negligent act of
commission or omission.
Whether electing or rejecting coverage, it will be necessary to complete the information as requested below. This
completed form must then be returned to the carrier/producer. A copy of this Notice and proof of mailing should
be retained for your records.
NAME OF BUSINESS_______________________________________________________________________________________
Always
complete
BUSINESS IS A CORPORATION or
this section
COVERAGE IS ELECTED _____COVERAGE IS REJECTED
______
OTHER FORM OF ORGANIZATION ______
Estimated
Name(s) of Proprietor or ALL Partners
Annual Wage
Duties
(please print)
Complete
1.____________________________
__________
_____________________________________________
this section
2.____________________________
__________
_____________________________________________
only when
3.____________________________
__________
_____________________________________________
coverage
4.____________________________
__________
_____________________________________________
is elected
5.____________________________
__________
_____________________________________________
6.____________________________
__________
_____________________________________________
Always
Signature:___________________________________________
Date:___________
complete
Proprietor or a Partner
this section
Form PP-1 A 7/01
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal