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

Sample Waiver Form - California Department Of Insurance Page 4

SAMPLE WAIVER FORM

Insured Name:

Insurer:

Policy No.:

GENERAL PARTNERS AND LLC MANAGING MEMBERS - WAIVER OF WORKERS’

COMPENSATION COVERAGE

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

that I am a general partner (if the insured is a partnership) or a managing member (if the

insured is a limited liability company) of the above-named insured. As a qualifying general

partner or managing member, 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 partnership’s or 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 insurance policy with the

above-referenced insurer if an employment-related injury occurs.

______________________________________

____________________________________

PRINT GENERAL PARTNER’S/

TITLE

MANAGING MEMBER’S FULL NAME

______________________________________

____________________________________

GENERAL PARTNER/MANAGING MEMBER

DATE

SIGNATURE

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 4