STATE OF NEW HAMPSHIRE
Department of Labor
P.O. Box 2080
Concord, NH 03302-2080
(603) 271-3175
EXCLUSION OF EXECUTIVE OFFICERS OR MEMBERS
INCLUSION OF SOLE PROPRIETORS OR PARTNERS
Instructions:
Exclusions: Any executive officers or members in excess of THREE are considered employees and cannot be excluded. A
new form must be filed any time there is a change in the three or less executive officers or members that are being excluded.
Each time the form is completed ALL excluded officers or members must be listed. A new 6WCex voids any previously
filed 6WCex form. A copy of this form shall be sent to each executive officer or members listed below by Certified Mail.
Inclusions: Any changes to elective coverage may be listed in Section 4.
1.
Date:_______________________________
Effective date:________________________________
CARRIER INFORMATION:
______________________
___________________________________________________________________
Carrier No.
Carrier Name and Address
AGENT INFORMATION:
___________________________________________________________________________________________
Agent Name and Phone Number
EMPLOYER INFORMATION:
_____________________
___________________________________________________________________
Employer Federal ID No.
Employer Name and Address
2.
EXCLUDED OFFICERS OR MEMBERS:
(Specific title must be provided. If a corporation, title such as President, Vice President, Treasurer or
Secretary. If Limited Liability Co., Member or Manager)
____________________________________________________________________________________________
Social Security Number/DOB
Name and Address
Specific Title
____________________________________________________________________________________________
Social Security Number/DOB
Name and Address
Specific Title
____________________________________________________________________________________________
Social Security Number/DOB
Name and Address
Specific Title
3.
All officers or members no longer excluded.
4.
This section is for elective coverage ONLY per RSA 281-A:2 VI (a)
____________________________________________________________________________________________
Social Security Number
Date of Birth
Name
____________________________________________________________________________________________
Social Security Number
Date of Birth
Name
____________________________________________________________________________________________
Social Security Number
Date of Birth
Name
Form 6WCex (Rev. 3/13)