Insurance WC Non Elect Form

INSURANCE WC NON ELECT FORM

Insured / Applicant Information

Insured Name:

Employer Identification Number (EIN)/Tax ID:    Phone:

Contact Person:    Email:

Policy Details

Insurer Name:

Policy Number:    Policy Type:

Policy Period From:    To:

Coverage Limit (Workers' Compensation): $    Employer's Liability Limit: $

Deductible: $    Annual Premium: $

Coverage Election / Non-Election

By completing this form, the Applicant elects the status indicated below for the persons listed in the Exclusions section. The Applicant understands that a valid election will affect coverage and statutory benefit eligibility as described in this form.

Exclusions — Persons Not Electing Coverage

The following individuals are expressly excluded from coverage under the policy referenced above. Applicant affirms that exclusion is made with the authority required by the policy and the Applicant's corporate/organizational documents.

Basis for Exclusion (check applicable):

Beneficiary Designation (Optional)

If the Applicant elects to designate beneficiaries for any employer-provided death or supplementary benefits, provide beneficiary information below. This designation applies only to benefits expressly offered by the policy or employer and does not alter statutory workers' compensation beneficiaries established by law.

Relationship:    Percentage:

Acknowledgements, Declarations, and Certifications

I, the undersigned Applicant, declare under penalty of perjury and on behalf of the named Insured that the information provided in this Insurance WC Non Elect Form is true, complete, and accurate to the best of my knowledge. I further certify:

1. That the persons listed in the Exclusions section are excluded from coverage under the policy specified above effective as of the effective date stated, and that such persons understand and accept that they will not be eligible for workers' compensation benefits under this policy for injuries occurring while excluded.
2. That the Applicant has authority to make this election on behalf of the Insured and will maintain records documenting such authority and the informed election of any excluded individual.
3. That the Applicant shall notify the Insurer promptly and in writing within thirty (30) days of any change in status of any excluded individual or any circumstance that would affect coverage under the policy.
4. That this election is subject to applicable law and may be ineffective if not permitted by controlling statute or regulation; the Applicant acknowledges that statutory beneficiaries and rights may supersede private designations to the extent required by law.
5. That the Applicant agrees to indemnify and hold harmless the Insurer for any losses, costs, or liabilities arising from misrepresentation or failure to disclose material facts relating to this election.

By checking the box below and signing this form, I affirm that I have read and understand the foregoing statements and that I authorize the Insurer to process this non‑election and amend the policy records accordingly.

Supporting Documentation Checklist

Provide copies of documents that substantiate exclusion basis for each person listed above. Check all documents attached:

Notice to Applicant

This form is a record of the Applicant's election to exclude persons from the referenced policy. The Insurer will rely on the representations made herein when amending policy records. Any material misrepresentation, omission, or failure to provide supporting documentation may render the election void and may subject the Applicant to denial of claims, rescission of coverage, premium adjustment, or other remedies permitted by the policy and applicable law.

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