Sample Waiver Form - California Department Of Insurance (Page 3 of 4) in pdf

Sample Waiver Form - California Department Of Insurance Page 3

SAMPLE WAIVER FORM

Insured Name:

Insurer:

Policy No.:

CORPORATE OFFICERS/DIRECTORS - WAIVER OF WORKERS’COMPENSATION COVERAGE

Pursuant to California Labor Code section 3352(p), I hereby certify, under penalty of perjury,

that I am an officer or director of the above-named insured, which is a quasi-public or private

corporation, and that I own at least 15 percent (15%) of the issued and outstanding stock of

the above-named insured corporation. As a qualifying officer or director, I elect to be excluded

from the corporation’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 corporation’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 OFFICER’S/DIRECTOR’S FULL NAME

TITLE

_______________________________________

____________________________________

OFFICER/DIRECTOR SIGNATURE

DATE

ACCEPTED:

____________________________________

_____________

[Insurance Company]

DATE

NOTE TO EMPLOYER: The exclusion will be endorsed to the policy 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: xxx

Sample Waiver Form - California Department Of Insurance Page 3