Fill and Sign the Claims Formsworkers Compensation Commission South

This form may be used when an officer desires to become exempt from the provisions of the Sou th Carolina Workers’ Compensation Act. For additional information regarding the provision of Section 42 - 1 - 520 and this form, contact your insurance carrier or the South Carolina Workers’ Compensation Commission, Coverage Division, Post Office Box 1715, Columbia, South Carolina 29202-1715. (803) 737-6203 . WCC Form # 5 Rev. 07/96 5 Corporate Officer Notice to Reject S outh C arolina Workers’ Compensation Commission 1333 Main St reet, Suite 500 P.O. BOX 1715 Columbia, SC 29202 - 1715 (803) 737-6203 CORPORATE OFFICER NOTICE TO REJECT To the Employer of the Undersigned and the Empl oyer’s Insurance Carrier: The undersigned officer rejects the terms, conditions, and provisions of the South Carolina Workers’ Compensation Act and elects to pursue compensation for personal injuries under the common law and statutes of South Carolina. A s provided by law (Section 42 - 1 - 520 ) , “An officer of a corporation who elects not to operate under this title shall, in any action to recover damages for personal injury or death brought against an employer accepting the compensation provisions of this tit le, proceed at common law and the employer may avail himself of the defenses of contributory negligence, negligence of a fellow servant, and assumption of risk, as such defenses exist at common law.” This notice becomes effective on the date listed below, no sooner than the day following the date signed by the corporate officer. ** PLEASE PRINT OR TYPE ALL INFORMATION ** ORIGINAL SIGNATURES REQUIRED ** Name of Officer Corporate Title Name of Business (Legal Name) Street Address P.O. Box Street Address P.O. Box City State Zip City State Zip Social Security Number Federal Employer ID # Area Code Telephone Number Area Code Telephone Number Signature of Officer Date Effective Date Subscribed and sworn to me this day of , . My Commission Expires: Notary Public