Ic52 Election Of Coverage printable pdf download

Ic52 Election Of Coverage

IC52 ELECTION OF COVERAGE

Check the appropriate box

Election

Revocation of Election

The undersigned hereby notifies the Industrial Commission of the following:

Household domestic service

Casual employment

Employment of outworkers

Employment of members of an employer's family dwelling in his household.

(Applies only to sole-proprietorships)

Employment as the owner of a sole proprietorship

Employment of a working member of a partnership or a limited liability company

(Circle either partnership or Limited Liability Company; if the election applies only to

certain partners/members, name the covered partners/members.)

Employment of an officer of a corporation who at all times during the period

involved owns not less than ten percent (10%) of all of the issued and outstanding

voting stock of the corporation and, if the corporation has directors, is also a

director thereof (If the election applies only to certain corporate officers, name the

covered officers)

Employment for which a rule of liability for injury, occupational disease, or death

is provided by the laws of the United States

Pilots of agricultural spraying or dusting planes

Associate real estate brokers and real estate salesmen paid solely by commission

Volunteer ski patrollers

Officials of athletic contests involving secondary schools

(Name of Insurance Company)

Policy Number _________________________________________________

Insured Name __________________________________________________

Effective Date of Election/Revocation ________________________

_______________________________________

____________________________________

(Signature of authorized representative)

(Employer's signature)

Ic52 Election Of Coverage