Form Db-212.3 - Notice Of Election
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1
2State of New York
WORKERS' COMPENSATION BOARD
NOTICE OF ELECTION OF A CORPORATION WHICH IS REQUIRED TO HAVE DISABILITY
BENEFITS COVERAGE FOR ITS EMPLOYEES UNDER THE DISABILITY BENEFITS LAW TO
EXCLUDE THE SOLE SHAREHOLDER-OFFICER OR ONE OF THE TWO OR BOTH
SHAREHOLDER-OFFICERS OF THE CORPORATION FROM SUCH COVERAGE
To: (Print name and address of insurance carrier here.)
TAKE NOTICE that under the provisions of Section 212, subdivision 4 of the Disability Benefits Law as amended, the corporation
named below elects to exclude the executive officer(s) named below from coverage under the New York State Workers'
Compensation Law with respect to all the policies issued to the corporation by the insurance carrier named above.
Name of Corporation ____________________________________________________________________________________
Address of Corporation __________________________________________________________________________________
Incorporated Under the Laws of the State of __________________________________________________________________
Type:
One-person corp.
Two-person corp. (A two-person corporation may elect to exclude one or both executive officers,
provided that between them they own all the stock in the corporation, and that each officer owns at least one share of stock.)
Executive Officer(s)
1. Name ______________________________________ Title ________________________________
to be excluded from
policy
2. Name ______________________________________ Title ________________________________
CERTIFICATION
USE FOR ONE-PERSON CORPORATION
I, _________________________________________________, certify that I am the sole executive officer of the above-named
Name
corporation; that I have been since __________________the sole owner of all issued and outstanding stock of the corporation
Date
and hold all the offices pursuant to paragraph (e) of Section 715 of the Business Corporation Law. (Affix corporate seal below,
if you have one.)
________________________________________________ ______________________ __________________________
Signature of Officer
Date
Telephone No.
USE FOR TWO-PERSON CORPORATION
We, _______________________________ , _____________________________ and _______________________________,
Name
Title
Name
___________________________________ certify that we are the two executive officers of the above-named corporation,
Title
having been duly appointed by corporate resolution; that we have been since _____________________ the sole owners of all
Date
issued and outstanding stock and that each of us owns at least one share of stock of the corporation, and that we hold all of the
offices pursuant to paragraph (e) of Section 715 of the Business Corporation Law. (Affix corporate seal below, if you have one.)
________________________________________________ ______________________ __________________________
Signature of Officer
Date
Telephone No.
________________________________________________ ______________________ __________________________
Signature of Officer
Date
Telephone No.
CORPORATE
THIS ELECTION IS FINAL AND BINDING UPON THE
SEAL*
OFFICER(S) NAMED UNTIL REVOKED BY THE CORPORATION.
*If the corporation does not
q
have a seal, check here
See reverse side for relevant portions of Section 212, subd. 4 (DBL) and Sec. 715, Par. (e) of the Business Corporation Law.
DB-212.3 (1-04)
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