Fill and Sign the New Mexico Workers Comp Forms Workers Compensation Shop

STATE OF NEW MEXICO WORKERS’ COMPENSATION ADMINISTRATION EXECUTIVE EMPLOYEE AFFIRMATIVE ELECTION FORM I, ___________________________ (Please print name), am a “worker” as defined in the New Mexico Worker s’ Compensation Act and the New Mexico Occupational Diseas e Disablement Law (“the Acts”). I am employed by ________________________________ (Name of corporation or limited liability company), a company subject to the provisions of the Acts. Pursuant to NMSA 1978, §52-1-7 or §52-3-6, I affirmatively elect NOT TO ACCEPT the provisions of the Acts. I meet the qualifica tions set forth in §52-1-7 or §52-3-6 as follows: ▪ I am the chairperson of the board, pr esident, vice president, secretary, treasurer, or other executive officer of the employer corporation or limited liability company; and ▪ I own ten percent or more of the outstanding stock of the employer corporation or have at least a ten percent ownership interest in the employer limited liability company If my business is licensed with the Construction Industries Division or is engaged in business activities that fall under the Construction Industries Licensing Act I understand that all employees, including those hired on a temporary basis, are required to be covered by worker s’ compensation insurance unless they are an executive employee and have filed an affirm ative election form to not accept the provisions of the Act. I understand that I may face significant monetary penalties, up to $1,000 for each occurrence, and that my business may be shut down, if my business fails to secure work ers’ compensation insurance when it is required. I also understand that if my business fails to obtain workers’ compensation insurance when it is required to , I may be responsible for the costs associated with any claim for workers’ compensation benefits, including the costs of medical and disability payments. I understand that by making this affirmative election, it applies to all corporations or limited liability companies in which I have a financial interest. I understand that if I wi sh to revoke my election, I am required by law to file a revocation with my insurance carrier and with the Worker s’ Compensation (“WCA”) Director’s Office, and to mail a copy of the revocation to the board of directors of empl oyer corporation or limited liability company. I also agree to notify the WCA of any changes in my §52-1-7 or §52-3-6 status. I further understand that by making this election not to accept the provisions of the Acts, I will not be entitled to workers’ compensation benefits from the Uninsured Employers’ Fund. I swear or affirm under penalty of perjury that I have read the foregoing affirmative election in its entirety and understand the information contained therein is true and correct to the best of my knowled ge. Signature: ______________________________________ UI Number: ______________________ Executive Title: _________________________________ FEIN Number: ____________________ Business Address: ________________________________ Phone Number: ___________________ City/State/Zip: ___________________________________ STATE OF ______________________ ) ) s s. COUNTY OF ____________________ ) SUBSCRIBED AND SWORN OR AFFIRMED to before me on the _______ day of ______________, 20_______ by ____________________________________________. ________________________________ N ota ry P ublic My commission expires: ____________________ Please retain a copy of th is form for your records. 10/4/11