Form 07-6131 - Petition For Executive Officer Waiver printable pdf download

INSTRUCTIONS FOR PETITION FOR EXECUTIVE OFFICER WAIVER

Provide the exact legal corporate name as it appears on the Certificate of Incorporation, and the corporation’s federal

No. 1.

employer identification number (federal tax ID number).

No. 2.

Provide the corporate mailing address. This is the address where the original waiver should be mailed.

No. 3.

Provide the name, mailing address and title of each person for which waiver is sought.

No. 4.

Provide the name, address and telephone number of the person completing the application.

A completed Petition for Executive Officer Waiver (Form 07-6131) must be submitted to:

Alaska Department of Labor & Workforce Development

Workers’ Compensation Division

P.O. Box 115512

Juneau, Alaska 99811-5512

Telephone: (907) 465-2790

Facsimile: (907) 465-2797

BEFORE A WAIVER CAN BE ISSUED:

Each officer must read and sign the Affidavit of Corporate Officers form. Each officer’s signature must be signed before a

Notary Public. Be advised that the Alaska Corporate Code (AS 10.06) requires each corporation to have at least a President

and a Secretary. The office of President and Secretary cannot be held by one individual, unless that person is the sole

shareholder.

The following items must be included with the Petition for Waiver and Affidavit of Corporate Officers:

A copy of the page(s) of the most recently adopted corporate by-laws, including the articles or sections that describe the

officers’ titles and duties; and

A copy of the minutes of corporate meeting, verifying the petitioner’s election or appointment as an executive officer.

If the corporation’s status is not current with the Alaska Division of Corporations, Business, and Professional Licensing, a

Certificate of Compliance must accompany the petition. If you are unsure of your corporate status, contact the licensing

section at (907) 465-2534.

The names of the executive officers contained in the petition will be verified against the records of the Alaska Division of

Corporations, Business, and Professional Licensing. If there is a discrepancy, the petition may be held in pending status until

the corporation updates its officer and director information with the licensing section.

A waiver will not be approved until all information requested has been received by the Workers’ Compensation Division.

A waiver

cannot be issued retroactively.

AMENDING EXISTING WAIVERS

To add or change executive officers, a new waiver application, form 07-6131 must be submitted. The petition must state the names,

titles and addresses of each new executive officer or for each officer whose title has changed. An affidavit form must be signed and

notarized by each individual listed in the petition. The application for amended waiver must be accompanied by a copy of page(s) of

minutes of corporate meeting that reflects the changes in corporate officers.

To delete an executive officer from a waiver, or cancel a waiver, the corporation must submit a written request to have the officer

removed or the waiver cancelled. The request must be signed by the person who was covered under the waiver, or by the president of

the corporation.

Form 07-6131 (Revised 8/15/2007)

Form 07-6131 - Petition For Executive Officer Waiver