Fill and Sign the Executive Employee Exclusion Form New Mexico Mutual

STATE OF NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION REVOCATION OF PRIOR ELECTION FORM RE: _________________________________________________________________________ (Please clearly print name of business) ( ) Corporation ( ) Partnership ( ) Sole Proprietorship ( ) Limited Liability Company You are notified that the undersigned hereby waiv es and revokes previously filed forms, as checked below: (check one) ( ) Executive Employee Affirmative Election Form (NMSA 1978, §52-1-7) ( ) CID Sole Proprietor Affirmative Election Form (NMSA 1978, §52-1-7) ( ) Election to Accept Form (NMSA 1978, §52-1-6) Revocation is specifically provided for by NMSA 1978, §52-1-7. The undersigned acknowledges that this revocation shall become effective thirty ( 30) days after filing the same with the Workers’ Compensation Administration. If this revocation revokes a prior election not to be subject to the New Mexico Workers’ Compensation Act and the New Mexico Occupational Disease a nd Disablement Law, the undersigned hereby acknowledges acceptance of the terms, conditions, and provisions of these laws. Signature: _______________________________________ UI Number: ______________________ Print name: ______________________________________ FEIN Number: ____________________ Title: _________________ ______________________ ____ Phone Number: ___________________ Business Address: _______________ __________________ City/State/Zip: ____________________ STATE OF ______________________ ) ) ss. COUNTY OF ____________________ ) SUBSCRIBED AND SWORN OR AFFIRMED to before me on the _______ day of ______________, 20__________ by _________________________________________. ________________________________ Notary Public My commission expires: ___________________ Please retain a copy of this form for your records. 10/4/11