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Ny Revocation Corporation Unincorporated Form
Provisions of Section 54, subdivision 6, of the New York Workers' Compensation Law as amended, the
corporation or association named below hereby revokes, effective as provided by law, the election now in effect to exclude the unsalaried
executive officer named below from coverage under the New York State Workers' Compensation Law, with respect to all the policies
issued to the corporation or association by the insurance carrier named above.
Name of Corporation or...
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