Is an electronic signature valid on this form?

Yes, electronic signatures can be legally binding under the ESIGN Act (15 U.S.C. §7001) and UETA in adopted jurisdictions, provided intent, consent, attribution, and record retention are satisfied.

When is notarization or witness required?

Some states or employers may require a notary or witness for certain acknowledgements; verify local rules and include required lines before execution to avoid invalidation.

Can an employee revoke a non-election?

Revocation policies depend on statute and the form’s language; permit changes only if authorized and ensure a new signed document records the revocation and effective date.

Where should signed copies be stored?

Store executed forms in secure HR or benefits records with access controls, retain the audit trail, and follow retention rules such as IRS and HIPAA requirements where applicable.

What if the form is incomplete or ambiguous?

An incomplete or unclear non-election may be unenforceable and expose the employer to coverage disputes; correct issues promptly and re-execute if necessary with clear wording.

Who determines signatory authority?

Authority should be verified by employer policy or corporate resolution; if a third party signs on behalf of an employer, include evidence of authorization in the file.

Electronic Signature
Templates
Insurance
Insurance WC Non-Election Form

Insurance WC Non-Election Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Insurance WC Non-Election Form

Insured / Employer Information

Insured / Employer Name Doing Business As (DBA) Federal Tax ID / FEIN Mailing Address

Contact Person

Phone

Email

State(s) of Operation

Policy Number (if applicable)

Policy Period Start:

Policy Period End:

Entity Type

Select the legal entity type for the insured (check all that apply):

Sole Proprietor
Partnership
Corporation
Limited Liability Company (LLC)
Other (describe below)

If Other, describe

Non-Election Declaration

By completing and signing this form, Insured affirms that the following named individual(s) are not to be included as persons covered under the workers' compensation insurance policy of the Insured effective . Insured acknowledges that this non-election is made pursuant to applicable law and that the Insured accepts sole responsibility for providing any benefits, remuneration, or other compensation required by law to such excluded persons. Insured further acknowledges that non-election may affect the availability of statutory benefits to the excluded persons and may create direct liability for the Insured.

Individuals Excluded from Coverage

List all individuals for whom workers' compensation coverage is expressly declined. Provide full legal name, title/relationship to business, date of birth, last four digits of Social Security Number, and percent ownership if applicable.

Excluded Individual 1 — Full Legal Name

Title / Relationship:

Date of Birth:

SSN Last 4:

% Ownership:

Excluded Individual 2 — Full Legal Name

Title / Relationship:

Date of Birth:

SSN Last 4:

% Ownership:

Excluded Individual 3 — Full Legal Name

Title / Relationship:

Date of Birth:

SSN Last 4:

% Ownership:

Additional Excluded Individuals / Notes

Coverage Acknowledgements

The Insured affirms each of the following (check to indicate understanding and acceptance):

I accept sole responsibility and liability for providing any statutory benefits, wages, or medical care that may be owed to the excluded individual(s).
I understand workers' compensation coverage will not be provided for the listed individual(s) under the policy named above effective the date stated in this form.
I certify that the statements in this form are complete and will be relied upon by the insurer in determining coverage obligations; false statements may be grounds for denial of claims or rescission of coverage.
I acknowledge that state law may restrict or condition non-election; I have obtained any required consents or have otherwise complied with applicable statutory requirements prior to making this non-election.

Exclusions and Limitations

The insurer retains all rights under the policy. This declaration does not extend coverage to any person otherwise excluded by policy terms. Typical exclusions include, but are not limited to, intentional acts, injuries arising from non work-related activities, punitive damages, and claims barred by statute. The insurer may require additional documentation to confirm the status and eligibility of excluded individuals.

Beneficiary Designation (If Applicable)

For the limited purpose of distributing any death benefits payable under applicable law or policy provisions, identify beneficiary(ies) who should receive such proceeds in the event an excluded individual suffers a compensable fatality. The Insured acknowledges that legal beneficiaries under statute may supersede this designation.

Beneficiary Full Legal Name

Relationship to Excluded Individual

Allocation Percentage

Documentation Checklist

Attach or indicate which documents are provided to substantiate non-election and ownership status:

Signed corporate/partnership/ownership agreement
Recent tax returns showing ownership
Government ID copies of excluded individual(s)
Other supporting documentation (describe below)

Describe Other Documentation

Certification

I certify, under penalty of perjury and to the best of my knowledge, that the information provided in this Insurance WC Non-Election Form is true, accurate, and complete. I understand that the insurer will rely on this declaration in determining coverage and premium obligations. I acknowledge that any misrepresentation may be grounds for rescission of coverage or denial of claims and may subject me to civil or criminal penalties under applicable law.

Additional Remarks

Applicant / Authorized Representative:

Title:

Signature:

Date Signed:

Authorized Representative Email:

What the Insurance WC Non-Election Form Is and when it applies

The Insurance WC Non-Election Form is a written record used to document an employer or employee decision not to elect a particular workers’ compensation option where state law permits. It typically identifies the employer and affected worker(s), states the specific non-election or waiver, records effective dates, and notes any alternative coverage arrangements. Employers and insurers use the form to create an auditable record for underwriting, payroll, and regulatory review. Because statutory authority varies, whether a non-election is valid depends on state rules and the precise language used on the form.

Why keeping a clear non-election record matters

A completed Insurance WC Non-Election Form documents intent, reduces disputes about coverage, and helps insurers and regulators determine eligibility and premium treatment. It creates a dated, signed record employers can rely on during audits, claims reviews, or coverage disputes.

Who typically completes and relies on this form

Typical users include employers, insurance administrators, and HR professionals responsible for managing workers’ compensation elections and documentation.

Employers and HR teams managing coverage elections and documentation in multi-state operations.
Insurance carriers and underwriting teams reviewing non-election impacts for policy coverage and premium calculations.
Benefits administrators and legal counsel who verify compliance, retain records, and respond to regulator inquiries.

Where permitted by state law, coordinate completion with legal counsel and your insurance representative to confirm validity and required routing.

Who signs and who approves

HR Manager

Responsible for presenting the form to employees, ensuring required fields are completed, and keeping the executed copy in the personnel file. The HR manager should confirm state-specific requirements and coordinate with benefits or legal teams when alternative coverage is involved.

Risk Manager

Manages insurer notification and internal risk records, assesses the impact of a non-election on premiums and claims exposure, and escalates to legal counsel when statutory ambiguity or multi-state conflicts arise.

Essential parts of a professional Non-Election Form

A concise, well-structured form reduces ambiguity and improves enforceability by combining identification, a clear election statement, and signature verification.

Form header

Includes employer name, policy or account number, form ID, and the date the form was prepared to create an auditable record and link the form to coverage.

Statement of non-election

A clear, unambiguous sentence that describes the specific option being declined or waived and the scope (employee, class of employees, temporary or permanent).

Effective dates

Start and end dates for the non-election or the triggering event; these dates determine when coverage changes take effect and affect claims handling.

Alternative coverage

If another benefit or private plan replaces workers’ compensation rights, describe it briefly and attach supporting policy details or proof of coverage.

Signatory details

Printed name, title, organization, and contact information for each signer so the signature can be attributed to an authorized person.

Signature and witness

Signature block with signer, date, and any required witness or notary lines based on state law and the employer’s policies.

Step-by-step: complete and record the form

Follow a consistent sequence to ensure the form is valid, attributable, and stored where it can be retrieved for audits or claims.

01

Prepare: Populate employer and employee details and state the non-election text clearly.
02

Notify: Provide the form and required disclosures to affected employees for review before signing.
03

Sign: Obtain required signatures, witnesses, or notarization in accordance with state rules.
04

File: Save executed copies with HR, insurer, and any required regulator or benefit administrator.

How to configure an online non-election workflow

Configure fields and authentication to match your compliance needs before sending the form for signature.

Field	Configuration
Authentication method	Email link + SMS code or ID proofing where required
Field validation	Require MM/DD/YYYY for dates and enforce required fields
Retention policy	Automate archival and access controls per company retention rules
Notifications	Add HR, risk, and insurer recipients for completed forms

Where to send and file the completed form

After execution, distribute signed copies to the parties that require notice and file according to internal and regulatory needs.

Employee copy: Provide the signer a completed PDF for their records
Employer file: Store the executed form in the personnel or benefits file
Insurer: Send a copy to the carrier for underwriting and claims handling
Regulator: File with the state agency only where required by law

Digital signing and technical considerations

Choose an eSignature platform that supports required authentication, preserves an audit trail, and keeps a tamper-evident copy of the executed form.

Integrations: Salesforce, NetSuite, Google Workspace
File formats: PDF, DOCX, HTML
Security: TLS in transit, AES-256 at rest

Timing: common submission and retention windows

Timing requirements vary by state and policy. Use prompt distribution and clear deadlines to reduce disputes and ensure timely insurer notice.

Issue when coverage changes:

Provide the form before the effective date of any coverage change

Employee response period:

Allow reasonable time for signature and review per company policy

Notify insurer promptly:

Send executed forms to the carrier as required for underwriting

Regulatory filing:

File with state agency only if statute or rule requires

Retention trigger:

Retention begins at execution date for recordkeeping purposes

Key milestones for processing and retention

A simple four-stage timeline helps ensure accuracy, proper authorizations, and retrievability of the executed form.

01

Prepare document

Complete employer and employee sections before distribution

02

Execute signatures

Collect signer, witness, and notary actions as required

03

Distribute copies

Send executed copies to employee, HR, and insurer

04

Archive securely

Store for the retention period consistent with policy and law

Common mistakes to avoid when preparing this form

Using vague or ambiguous language for the non-election statement that creates uncertainty about what is being declined and who is affected.
Failing to include or validate effective dates so coverage and claims handling cannot be tied to a clear time window.
Not obtaining required witness or notary signatures where state law or company policy mandates additional authentication.
Storing only a scanned copy in an unsecured location without preserving the audit trail and signer attribution metadata.

Penalties and risks of incorrect or incomplete forms

Invalidity risk: Form may be unenforceable

Coverage disputes: Employees may claim coverage was retained

Regulatory action: Possible fines or corrective orders

Claims exposure: Insurer may deny premium adjustments

Privacy breaches: Improper handling of identifiers creates HIPAA/CCPA risks

Operational delays: Late notifications slow underwriting and claims

Practical tips to complete the form quickly and correctly

Follow these best practices to minimize rework and ensure the non-election is attributable and defensible.

Use precise, plain language

Draft the non-election statement with unambiguous terms, identify the specific coverage option being declined, and avoid legalese that could be interpreted in multiple ways.

Validate identity and authority

Confirm the signer’s authority to waive or decline coverage and use reliable authentication methods to attribute the signature correctly.

Preserve the audit trail

Keep timestamps, IP addresses, and the certificate of completion for e-signed forms; these elements help establish intent and consent.

Coordinate with insurer and counsel

Share draft language with the carrier and legal counsel when the consequences affect premiums, claims handling, or statutory rights.

Real-world examples of electronic form use

Organizations use digital signing to reduce turnaround time, preserve audit trails, and keep records accessible for audits or claims.

Optica Ventures LLC — Brian Fitzgibbons, COO

Optica automated signature workflows for compliance forms to reduce back-and-forth approvals.

Faster collection of signed documents for HR and risk teams.
"The interface is simple and easy-to-use for our team; more importantly, it is just as easy for our customers."

Martin Properties — Tim Martin, Founder

Property management digitized employee and contractor acknowledgements to avoid paper loss on field jobs.

Secure mobile signing on site or offline for contractor crews.
"I can process and execute all of these documents online with 100% compliance and built-in security. Whether on mobile or working offline, I can get forms back to their necessary parties efficiently."

eSignature vendor comparison for executing the Insurance WC Non-Election Form

Compare per-user starting price, trial availability, bulk send, audit trail, HIPAA coverage, and envelope limits to choose a platform that fits volume and compliance needs.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Frequently asked questions about validity, signing, and storage

Answers address common legal and practical questions. When in doubt about state-specific requirements, consult counsel or the relevant agency.

Need help? Contact support

Is an electronic signature valid on this form?
Yes, electronic signatures can be legally binding under the ESIGN Act (15 U.S.C. §7001) and UETA in adopted jurisdictions, provided intent, consent, attribution, and record retention are satisfied.
When is notarization or witness required?
Some states or employers may require a notary or witness for certain acknowledgements; verify local rules and include required lines before execution to avoid invalidation.
Can an employee revoke a non-election?
Revocation policies depend on statute and the form’s language; permit changes only if authorized and ensure a new signed document records the revocation and effective date.
Where should signed copies be stored?
Store executed forms in secure HR or benefits records with access controls, retain the audit trail, and follow retention rules such as IRS and HIPAA requirements where applicable.
What if the form is incomplete or ambiguous?
An incomplete or unclear non-election may be unenforceable and expose the employer to coverage disputes; correct issues promptly and re-execute if necessary with clear wording.
Who determines signatory authority?
Authority should be verified by employer policy or corporate resolution; if a third party signs on behalf of an employer, include evidence of authorization in the file.

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