Il Executive Officer Exclusion Form - Don R. Jensen & Company printable pdf download

Il Executive Officer Exclusion Form - Don R. Jensen & Company

NOTICE TO REJECT COVERAGE UNDER

ILLINOIS WORKERS COMPENSATION LAW

Effective 6‐1‐2015, Illinois Workers Compensation Law has changed regarding LLC members, corporate

officers, sole proprietors and partners. All LLC members, corporate officers, sole proprietors and partners

are automatically covered under the Illinois Workers Compensation Act unless they elect not to receive

such coverage.

Since this ruling affects your coverage and premiums, we are requesting a complete list of all sole

proprietors, partners, members and corporate officers that elect not to be covered under the Illinois

Workers Compensation Act and the Workers Compensation policy.

Insured Name:_____________________________________________________________________

Address:__________________________________________________________________________

Entity: ____ Sole Proprietor ____ Partner ____ Corporation ____ Limited Liability Corporation

Policy Period: From___________________ to __________________

The undersigned sole proprietor, partner(s), member(s) or corporate officer(s) of the above referenced business do

hereby reject coverage under the Illinois Workers Compensation Act and the Workers Compensation policy.

Type or print each name and title under signature.

Signature__________________________________________________Percentage of ownership_______

Name and Title:________________________________________________________________________

Signature__________________________________________________Percentage of ownership_______

Name and Title:________________________________________________________________________

Signature__________________________________________________Percentage of ownership_______

Name and Title:________________________________________________________________________

Effective date of Rejection____________________Date signed:_________________________________

Use additional copies as needed.

Il Executive Officer Exclusion Form - Don R. Jensen & Company