Form Dcrb-Excl - Agreement By Executive Officer(S)/llc Member(S) Not To Be Subject To The Delaware Workers' Compensation Law

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AGREEMENT BY EXECUTIVE OFFICER(S)/LLC MEMBERS(S) NOT TO BE SUBJECT TO THE DELAWARE WORKERS’
COMPENSATION LAW
Executive officers of corporations and members of Limited Liability Companies (LLCs) are covered under the Delaware
Workers’ Compensation Law. However, up to eight (8) executive officers who are stockholders of a corporation or up to four
(4) members of an LLC may elect not to be subject to Delaware Workers’ Compensation Law by completing this agreement
with their corporation/LLC.
SPECIAL NOTE:
- CONSTRUCTION corporations/ LLCs subject to Title 30, Chapter 25 of the
Delaware Code may elect to exclude up to four (4) executive officers who are stockholders of a corporation or up to four (4)
members of an LLC. Executive Officers are the president, any vice president, secretary, treasurer or any other executive
officer(s) elected by the board of directors in accordance with the charter and the regularly adopted by-laws of the corporation.
This Executive Officer/LLC member Exclusion Procedure must be repeated each time a corporation/LLC wishes to change the
status of any executive officer/LLC member and/or secures coverage from a different carrier group.
Name of business
_____________________________________________________________________________________________
Address of business
_____________________________________________________
___________________ ______ __________
Street/Road/PO Box
Town/City
State
Zip code
Federal Employer Identification Number
Business has employee(s) (other than those listed below) - please check here ____
Business does not have employee(s) (other than those listed below) - please check here____
Please check type of business
□ Corporation Not Subject to Title 30, Chapter 25 (non construction) – Maximum 8 exclusions
□ Corporation Subject to Title 30, Chapter 25 (construction) – Maximum 4 exclusions
□ Limited Liability Company (LLC) – Maximum 4 exclusions
_____________________________________________________
____________
____________________
Signature of Representative of Corporation or LLC
Title
Date
Named below are the executive officer(s)/LLC member(s) electing not to be subject to the Delaware Workers
Compensation Law:
NAME(s)
MEMBER
STOCKHOLDER
(Print name)
TITLE
OFFICER(S) SIGNATURE
YES/NO
DATE
Additional space below cannot be used by Title 30, Chapter 25 corporations or any limited liability company.
IMPORTANT: If you have workers compensation insurance, you must submit the original of this completed form to
your insurance carrier, together (in the case of a corporation) with the shareholders resolution(s), shareholders
agreement(s), and/or shareholders written consent(s) evidencing the executive officer status of the electing executive
officer(s), or together (in the case of an LLC) with the operating agreement and/or certificate of formation evidencing the
member status of the electing member(s). If you are a subcontractor, you must also provide a copy of the same
documents to each general contractor by whom you are hired.
FORM DCRB-EXCL 12/09

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