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Limited Liability Company Managing Members - Waiver Of Workers' Compensation Coverage (California)

CALIFORNIA

LIMITED LIABILITY COMPANY MANAGING MEMBERS – WAIVER OF WORKERS’

COMPENSATION COVERAGE

NAME OF COMPANY: ________________________________________

FEIN: ___________________________

POLICY #: ______________________

Berkshire Hathaway GUARD Insurance Company:

AmGUARD

EastGUARD

NorGUARD

Pursuant to California Labor Code section 3352(q), I ____________________________________hereby

certify, under penalty of perjury, that I am a managing member of the above named insured. As a

qualifying managing member of the insured, I elect to be excluded from the insured’s workers’

compensation insurance policy with the above-referenced insurer.

I understand and agree that this written waiver will be effective upon the date of receipt and acceptance

by the limited liability company’s insurer and it shall remain in effect until I provide the insurer with a

written withdrawal of this waiver.

I understand and agree that by signing this waiver, I will not be entitled to coverage under the insured’s

workers’ compensation policy with the above-referenced insurer if an employment-related injury occurs.

__________________________________________________

____________________

PRINT MANAGING MEMBER’S FULL NAME

TITLE

__________________________________________________

____________________

MANAGING MEMBER’S SIGNATURE

DATE

NOTE TO EMPLOYER: This exclusion will apply upon our receipt and acceptance of a signed and

properly completed form. The person electing exclusion must sign this form. Company

representatives may not sign on behalf of the individual. One exclusion per form. Submit

additional forms if needed.

Submit forms to: Berkshire Hathaway GUARD Insurance Companies

PO Box A-H, Wilkes-Barre, PA 18703-0020

CA-OFFEXCL-01-15

Limited Liability Company Managing Members - Waiver Of Workers' Compensation Coverage (California)