Form 07-6131 - Petition For Executive Officer Waiver Page 3
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3AFFIDAVIT OF CORPORATE OFFICERS
Legal Name of Corporation
I, _________________________________________, being first duly
I, _________________________________________, being first duly
sworn, state I am a duly elected or appointed officer of the above named
sworn, state I am a duly elected or appointed officer of the above named
corporation. I request a waiver from coverage under the Alaska
corporation. I request a waiver from coverage under the Alaska
Workers' Compensation Act. I am voluntarily, without coercion, signing
Workers' Compensation Act. I am voluntarily, without coercion, signing
this waiver request. I understand that my rights to benefits under the Act
this waiver request. I understand that my rights to benefits under the Act
are waived and that this waiver extends to my beneficiaries in case of my
are waived and that this waiver extends to my beneficiaries in case of my
death from any injury sustained during the performance of my duties as a
death from any injury sustained during the performance of my duties as a
corporate executive officer.
corporate executive officer.
Signature Of Officer
Signature Of Officer
Signature of Notary Public
Signature of Notary Public
Notary Public in and for the State of
Notary Public in and for the State of
Subscribed to me this
day of
,
.
Subscribed to me this
day of
,
.
My Commission Expires:
My Commission Expires:
I, _________________________________________, being first duly
I, _________________________________________, being first duly
sworn, state I am a duly elected or appointed officer of the above named
sworn, state I am a duly elected or appointed officer of the above named
corporation. I request a waiver from coverage under the Alaska
corporation. I request a waiver from coverage under the Alaska
Workers' Compensation Act. I am voluntarily, without coercion, signing
Workers' Compensation Act. I am voluntarily, without coercion, signing
this waiver request. I understand that my rights to benefits under the Act
this waiver request. I understand that my rights to benefits under the Act
are waived and that this waiver extends to my beneficiaries in case of my
are waived and that this waiver extends to my beneficiaries in case of my
death from any injury sustained during the performance of my duties as a
death from any injury sustained during the performance of my duties as a
corporate executive officer.
corporate executive officer.
Signature Of Officer
Signature Of Officer
Signature of Notary Public
Signature of Notary Public
Notary Public in and for the State of
Notary Public in and for the State of
Subscribed to me this
day of
,
.
Subscribed to me this
day of
,
.
My Commission Expires:
My Commission Expires:
Form 07-6131 (Revised 8/15/2007)
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