Statement Of Workers' Compensation Insurance Form printable pdf download

Statement Of Workers' Compensation Insurance Form

STATEMENT OF WORKERS’ COMPENSATION INSURANCE

Maryland Code Annotated, Health-General Article, §1-202 requires that an employer must file

with the issuing authority: (1) a certificate of compliance with the Maryland Workers

Compensation Act; or (2) a workers' compensation insurance policy or binder number before any

license or permit is issued.

Please circle the number of the option below which best applies to you, provide the requested

information, sign, date the form, and return it with the attached application.

1. I have worker’s compensation insurance.

Insurance Company ____________________________________________

Policy or Binder Number ________________________________________

2. I do not have any covered employees as defined by Maryland Code Annotated, Labor and

Employment Article §9-202, and therefore, am exempt from having workers'

compensation insurance.

3. I am self-insured. Approval of self-insurance has been received from the Worker’s

Compensation Commission. (ATTACH A COPY OF THE CERTIFCATE OF

COMPLIANCE).

____________________________________________

_______________________

Signature

Title

________________________________________________________________________

Printed Name of Attester

______________________________________________

____________________

Business Name

Date

Statement Of Workers' Compensation Insurance Form