Sample Waiver Form - California Department Of Insurance printable pdf download

STATE OF CALIFORNIA

Dave Jones, Insurance Commissioner

DEPARTMENT OF INSURANCE

Office of the Commissioner

45 Fremont Street, 23rd Floor

San Francisco, CA 94105

John Finston

General Counsel & Deputy Commissioner

TEL: 415-538-4379

FAX: 415-904-5889

E-Mail: John.Finston@insurance.ca.gov

October 17, 2016

NOTICE TO ALL INSURERS, ADMITTED TO WRITE OR WRITING WORKERS’

COMPENSATION COVERAGES IN CALIFORNIA, REGARDING CHANGES IN

DEFINITIONS OF EMPLOYEE AND EXCLUSIONS TO THE DEFINITION OF

EMPLOYEE (OFFICERS AND MEMBERS OF BOARDS OF DIRECTORS, AND

PARTNERS) EFFECTIVE JANUARY 1, 2017 AS A RESULT OF ENACTMENT OF

AB 2883

As of the date of this notice, existing law defines an employee, for purposes of the laws

governing workers’ compensation, to include, among other persons, officers and

members of boards of directors of quasi-public or private corporations while rendering

actual service for the corporations for pay. Existing law excludes from that definition,

among other persons, officers and directors of a private corporation who are the sole

shareholders of the corporation and working members of a partnership or limited liability

company, as specified, unless they elect to come under the compensation provisions of

the laws governing workers’ compensation.

Effective January 1, 2017, AB 2883 (Assembly Insurance Committee) makes certain

changes to the definition of employee and exclusions to the definition of employee set

forth in sections 3351 and 3352 of the Labor Code. Specifically, officers and members

of boards of directors while rendering actual service for the corporation for pay will be

covered employees unless the officer or member of the board of directors owns at least

15 percent of the issued and outstanding stock of corporation and executes a written

waiver of his or her rights under the Labor Code stating under penalty of perjury that the

person is a qualifying officer or director. Similarly, working members of a partnership or

limited liability company receiving wages irrespective of profits from the partnership or

limited liability company will be covered employees unless the individual is a general

partner of a partnership or a managing member of a limited liability company and

executes a written waiver of his or her rights under the Labor Code stating under

penalty of perjury that the person is a qualifying general partner or managing

member. AB 2883 also amends Labor Code Section 3352 to provide that if a waiver is

executed, the waiver “shall be effective upon the date of receipt and acceptance by the

… insurance carrier ….”

Consumer Hotline (800) 927-HELP • Producer Licensing (800) 967-9331

Sample Waiver Form - California Department Of Insurance