Application For Exclusion/inclusion Mandatory Coverage printable pdf download

Application For Exclusion/inclusion Mandatory Coverage

MAIL FORM TO:

APPLICATION FOR

Employer Services

EXCLUSION/INCLUSION

Department of labor & Industries

PO Box 44144

MANDATORY COVERAGE

Olympia WA 98504-4144

(Family Farm)

(360) 902-4817

Under the provisions of RCW 51.12.020 as amended by House Bill 2322, I request my children listed

below be (excluded from or included in) mandatory workers' compensation coverage.

(Check

appropriate box below)

Exclusion

: I certify they are at least 18 years old and under 21 years old, that they are

employed in agricultural activities on our family farm, and that they reside with me or on the family

farm. This exclusion will be effective the date the department receives this exclusion, or on a later date

if indicated.

Inclusion

: I request my previously approved exclusion from coverage for my children be

canceled. I now want them to be covered by workers' compensation insurance. The cancellation of

exclusion will be effective the date the department receives this cancellation, or on a later date if

indicated.

The effective date of this action will be 12:01 a.m., Month

Day

Year

, but will not be

prior to the date the department receives this notification

Employer's name

Official position

State ZIP

Business address

City

L&I Account ID

Today's date

Signature of employer

Name(s) of children

Social Security Number

Date of Birth

F213-113-000 app for exclusion/inclusion mandatory coverage 5-96

Application For Exclusion/inclusion Mandatory Coverage