Workers' Compensation Board Notice Of Election Of A Partnership
Download a blank fillable Workers' Compensation Board Notice Of Election Of A Partnership in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Workers' Compensation Board Notice Of Election Of A Partnership with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2State of New York
THIS AGENCY EMPLOYS AND SERVES
PEOPLE WITH DISABILITIES WITHOUT
WORKERS' COMPENSATION BOARD
DISCRIMINATION.
NOTICE OF ELECTION OF A PARTNERSHIP, LIMITED LIABILITY PARTNERSHIP, PROFESSIONAL LIMITED
LIABILITY PARTNERSHIP, LIMITED LIABILITY COMPANY, PROFESSIONAL LIMITED LIABILITY COMPANY OR SOLE
PROPRIETORSHIP TO BRING PARTNERS, MEMBERS OR SELF-EMPLOYED PERSONS UNDER THE COVERAGE
OF THE NEW YORK STATE WORKERS' COMPENSATION LAW
THIS ELECTION IS EFFECTIVE
To: (Print name and address of insurance carrier here)
(Print name and address of insurance carrier here)
AS OF THE DATE FILED WITH
THE INSURANCE CARRIER
TAKE NOTICE that under the provisions of Sec. 54, subd. 8, of the New York Workers' Compensation Law as amended, the partnership
as defined in Section 10 of the Partnership Law of New York State or the limited liability partnership (LLP) or professional limited liability
partnership (PLLP) or limited liability company (LLC) or professional limited liability company (PLLC) or sole proprietorship named below
elects to bring the partners, members or self-employed persons listed herein under the coverage of the New York Workers' Compensation
Law with respect to all policies issued to the partnership, LLP, PLLP, LLC, PLLC or sole proprietorship by the insurance carrier named
above.
Name of Partnership, LLP, PLLP, LLC, PLLC or Sole Proprietorship________________________________________________________
Address________________________________________________________________________________________________________
(County Where Principal Office is Located)
This is a sole proprietorship having employees required to be covered under the NYS Workers' Compensation Law.
This is a partnership as defined in Section 10 of the Partnership Law of New York State, having employees required to be
covered under the NYS Workers' Compensation Law. This is not a limited partnership.
This is a limited liability partnership or professional limited liability partnership having employees required to be covered under the NYS
Workers' Compensation Law.
This is a limited liability company or professional limited liability company having employees required to be covered under the NYS
Workers' Compensation Law.
PARTNERS, MEMBERS OR SELF-EMPLOYED PERSONS TO BE INCLUDED IN POLICY
Name and Address of partners, members, or self-insured persons included in policy. Copy of this notice should be sent to each person named below.
I am a
general partner
sole proprietor
member
other (specify)_______________________________________________
of the herein named firm or company and certify that the above election to include partners, members or self-employed persons as set forth
above, was duly made by the partnership, company, or sole proprietorship and was entered upon the records of the firm or company.
Name of Firm or
Company____________________________________________________________________Date________________________
________________________________________________________________________________________________________
(Signature)
Type Name and Title
Telephone No.
PLEASE NOTE
This form applies only to the partners, members or self-employed persons here certified and should be sent at once to the insurance
carrier. A new Form C-105.32 must be filed whenever new or additional partners, members or self-employed persons are to be included
or when the insurance carrier is changed. For copy of Sec. 54, subd. 8, of the Workers' Compensation law and Sec.10 of the Partnership
Law see reverse side.
C-105.32 (4-04)
U-627 Front
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form C-251 - Carrier's Request For Reimbursement Of Compensation Payments - Workers' Compensation Board - State Of New York
Legal
Notice Of A Transaction Exempt Under Corporations Code Section 31106 - Department Of Corporations
Legal
Related Categories
Parent category: Legal