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STATE OF NEW MEXICO

WORKERS’ COMPENSATION ADMINISTRATION

CID SOLE PROPRIETOR AFFIRMATIVE ELECTION FORM

I, _____________________________________, (please print name) under penalty of perjury and after

having been duly sworn, state that I affirmatively elect NOT TO ACCEPT the provisions of the

Workers’ Compensation Act and the Occupational Disease and Disablement Law pursuant to NMSA

1978 §52-1-7 or §52-3-6. In support of this election, I affirm and acknowledge the following to be true:

1) I am the sole owner of ________________________________________________________.

(Name of business – please print clearly)

2) I own all the assets of my business and am solely liable for the debts of my business.

3) No one works for me in my business.

4) I have a license from the Construction Industries Division and I am engaged in business

activities that fall under the Construction Industries Licensing Act.

5) I understand that if I decide to hire any employee, even if on a temporary basis, I am required to

buy workers’ compensation insurance immediately and to notify the Workers’ Compensation

Administration.

6) I understand that I may face significant monetary penalties, up to $1,000 for each occurrence,

and that my business may be shut down if I fail to secure workers’ compensation insurance upon

hiring an employee, even temporarily.

7) I also understand that if I do hire an employee and fail to obtain workers’ compensation

insurance, I may be responsible for the costs associated with any claim for workers’

compensation benefits by such employee, including the costs of medical and disability

payments.

8) I further understand that by making this election not to accept the provisions of the Workers’

Compensation Act and Occupational Disease Disablement Law, I will not be entitled to

workers’ compensation benefits from the Uninsured Employers’ Fund.

Signature: _______________________________

UI Number: _____________________________

Business Address: ________________________

FEIN Number: __________________________

City/State/Zip: ___________________________

Phone Number: __________________________

STATE OF ______________________ )

) ss.

COUNTY OF ____________________ )

SUBSCRIBED AND SWORN OR AFFIRMED to before me on the _______ day of

______________, 20__________ by ______________________________________.

________________________________

Notary Public

My commission expires:

____________________

Please retain a copy of this form for your records.

10/4/11

Cid Sole Proprietor Affirmative Election Form - New Mexico Workers' Compensation Administration - 2011