Form Ic-16 - Officer Exclusion Form
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1MARYLAND WORKERS’ COMPENSATION COMMISSION
EXCLUSION FORM
INSTRUCTIONS: Pursuant to Labor & Employment Article §9-206, Annotated Code of Maryland, officers or
members of certain business entities may elect to be exempt from workers' compensation insurance
coverage by filing this Exclusion Form with the Commission. To exercise this option, the officer or member
making the election must sign this document. Submit the original form to the Workers’ Compensation
Commission, a copy to the insurer of the company/corporation, and keep a copy for your files.
Company Name: ______________________________________________________________________
Address: ____________________________________________________________________________
City: _____________________
State: ___________
ZIP _______________________
Type of Company:
___
Close Corporation
___
General Corporation
___
Farm Corporation
___
Professional Corporation
___
Limited Liability Company
Insurance Company Name: _____________________________________________________________
Date Insurance Company Notified: _________________
Typed Name and Title of the Officer
% of
Personal
or Member Electing Exclusion
Ownership
Signature
____________________________________
________
___________________
____________________________________
________
___________________
____________________________________
________
___________________
____________________________________
________
___________________
____________________________________
________
___________________
NOTE: By signing this Exclusion Form, each officer or member affirms under the penalties
of perjury that the information contained in this form is true and correct as to that officer or
member, to the best of the officer’s or member’s knowledge, information, and belief.
10 East Baltimore Street Baltimore, Maryland 21202-1641
410-864-5100 Email: info@wcc.state.md.us Web:
Form IC-16 (01/11)
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