Fill and Sign the Ic52 Election of Coverage Election Revocation Justia Form

IC52 ELECTION OF COVERAGE The undersigned hereby notifies the Industrial Commission of the following:  Household domestic service  Casual employment  Employment of outworkers  Employ ment of members of an employer's family dwelling in his household. ( Applies only to sole-proprietorships and single member limited liability companies that are taxed as a sole-proprietorship )  Employment as the owner of a sole proprietorship  Employmen t 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 (I f the election applies only to certain corporate officers, name the covered officers )  Employment for which a rule of liability for injury, occupational disease, or d eath is provided by the laws of the United States  Pilots of agricult ural spraying or dusting planes  Associate real estate brokers and real estate sal esmen paid solely by commission  Volunteer ski patrollers  Officials of athletic conte sts involving secondary schools ( Name of Insurance Company ) Policy Number _________________________________________________ Insured Name __________________________________________________ Effective Date of Election/Revocation ________________________ _______________________________________ ____________________________________ ( Signature of authorized representative ) (Employer's signature ) Check the appropriate box  Election  Revocation of Election