Workers' Compensation Election Of Coverage printable pdf download

Workers' Compensation Election Of Coverage

WORKERS’ COMPENSATION ELECTION OF COVERAGE

Minnesota Workers’ Compensation law (Minn.§ Stat. 176.041) exempts coverage for the following

employed persons and their spouses, parents or children (regardless of age or wage rate):

An individual owner of a business (a sole proprietorship).

A partner or partners of a partnership.

Executive officers of a closely held corporation in which the corporation has



capital stock held by no more than 10 persons.



less than 22,880 hours of payroll in the previous calendar year.



If both are applicable, only executive officers owning 25% or more of the stock are excluded

and must elect to be included.

Managers of Limited Liability Companies in which the LLC has:



10 or fewer members (i.e., owners)



less than 22,880 hours of payroll in the previous calendar year,



If both are applicable, only managers who own at least 25% membership interest are excluded

and must elect to be included.

Please complete this form with the name and title or relationship of all employed persons listed above.

Indicate by checking the appropriate box whether each person is to remain excluded for coverage or

whether coverage is desired.

Please print or type

Name of sole proprietor, partner, corporate officer or manager

of LLC electing or rejecting coverage.

Title

(and % of ownership)

SIGNATURE_______________________________________

TITLE ______________

DATE__________

Name of spouse, parent or child for whom insured is electing or

rejecting coverage.

Relationship

SIGNATURE_______________________________________

TITLE_____________

DATE_________

Policyholder name_______________________________ Policy number _________________

Return to SFM Risk Solutions, P O BOX 9403, Minneapolis MN 55440-9403

Workers' Compensation Election Of Coverage