Form 07-6131 - Petition For Executive Officer Waiver (Page 2 of 3) in pdf

Form 07-6131 - Petition For Executive Officer Waiver Page 2

PETITION FOR EXECUTIVE OFFICER WAIVER

ALASKA DEPARTMENT OF LABOR &

(For AWCB Use Only)

WORKFORCE DEVELOPMENT

Workers Compensation Board

P.O. Box 115512

(Type or Print)

Juneau, AK 99811-5512

An executive officer of a business corporation (AS 10.06), a cooperative corporation (AS 10.15), an electric and telephone

cooperative corporation (AS 10.25), or a professional corporation (AS 10.45) may waive their rights to benefits under the Alaska

Workers’ Compensation Act (AS 23.30). To receive an Executive Officer Waiver, the following completed form and attachments

must be submitted to the State of Alaska, Department of Labor & Workforce Development at the above address. An executive officer

means the president, vice-president, secretary, treasurer, or a corporate employee who is responsible for the corporation’s affairs

generally, has a close connection to the board of directors and other officers, and who is specifically designated as an executive officer

in the corporation’s minutes of record.

1. Legal Name of Corporation

2. Federal Employer Identification No.

3. Mailing Address of the principal business offices of the corporation

Name, corporate title, and mailing address of each person for whom an Executive Officer Waiver is

requested. (Attach a separate sheet of paper if more space is needed)

Name

Title

Mailing Address

Name

Title

Mailing Address

5. Name of Person Completing This Form

6. Telephone Number

Each officer listed must sign and have notarized the enclosed Affidavit of Corporate Officer form.

This Application must be accompanied by

A copy of the page or pages of the bylaws that state officer titles and duties

A copy of the page of the minutes of the corporate meeting that reflects the election or appointment

of the designated individuals as corporate executive officers

Form 07-6131 (Revised 8/15/2007)

Form 07-6131 - Petition For Executive Officer Waiver Page 2