Fill and Sign the Petition for Executive Officer Waiver Alaska Department of Labor Form

07-6131 (Rev 01/2018) ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Division of Workers’ Compensation P.O. Box 115512 Juneau, AK 99811-5512 PETITION FOR EXECUTIVE OFFICER WAIVER Original Amendment Cancellation An executive officer of a business corporation (AS 10.06), a co operative corporation (AS 10.15), an electric and telephone cooperative corporation (AS 10.25), or a professional corporation (AS 10.45) may waive their rights to benefits under the Alaska Workers’ Compensation Act (AS 23.30). To receive an Executive Officer Waiver, the following completed form and attach ments must be submitted to the Division of Workers’ Compensation at the above address. 1.Legal Name of Corporation 2. Federal Employer Identification No. 3. Entity Physical Address 4.Corporate Executive Officer(s) (Attach a separ ate sheet of paper if more space is needed) Name Name Title(s)Title(s) Mailing Address Mailing Address NameName Title(s)Title(s) Mailing Address Mailing Address 5.Requestors Name 6.Requestors Phone # 7. Requestors Email An executive officer means an employee of the corporation the presi dent, vice-president, secretary, treasurer, or a corporate employee who is responsible for the corporation’s affairs generally, has a close connection to the board of directors and other officers, and who is specifically designated as an executive officer in the corporation’s articles and bylaws. To obtain an Executive Officer Waiver, a corporation must satisfy the following requirements a.Each officer must read and sign the Affidavit of Corporate Officers form. Each officer’s signature must be signed before a Nota ry Public. Be advised t hat the Alaska Corporate Code (AS 10.06) requires each corporatio n to have at least a President and Secretary. The office of the President and Secretary cannot be held by one individual, unless that person is the sole shareholder b. The corporation’s status mu st be active and in good standing with the Alaska Division of Corporations, Business, and Profession al Licensing. If you are unsure o f your corporate status, cont act the licensing section at (907) 465-2534. c. The names of the executive officers contained in the petition mu st correlate with the listed officials found on the Alaska Division of Corporations, Business, and Professional Lice nsing website. d. The following must be included in this application. •A copy of the first page of articles of incorporation and page(s) of the bylaws that state officer titles and duties • A copy of the minutes of the corporate meeting that reflects the election or appointment of the designated individuals as corpo rate executive off icers Amending an existing Executive Officer Waiver: e. To add or c hange executive officers, a new petition must be submitted with an affidavit si gned and notarized by each individual listed in the petition. A copy of page(s) of minutes of corporate meeting that reflects the changes in corporate officers must be included. f. To remove an executive officer from a waiver, or cancel a waiver, the corporation must submit a written request to have the off icer removed or the waiver cancelled. The request must be signed by the person who was covered under the waiver, or by the president of the corpora tion. Please note: All documentation submitted is considered public information. Incomplete applications will be returned. 07-6131 (Rev 01/2018) AFFIDAVIT OF CORPORATE OFFICERS Legal Name of Corporation I, , being first duly sworn, state I am a duly elected or appointed officer of the above named corporation. I request a waiver from coverage under the Alaska Workers’ Compensation Act. I am voluntarily, without coercion, signing this waiver request. I understand that I will not qualify for benefits in the event of a work related injury sustained during the performance of my duties as a corporate executive officer. I, , being first duly sworn, state I am a duly elected or appointed officer of the above named corporation. I request a waiver from coverage under the Alaska Workers’ Compensation Act. I am voluntarily, without coercion, signing this waiver request. I understand that I will not qualify for benefits in the event of a work related injury sustained during the performance of my duties as a corporate executive officer. Signature O f Officer Notar y Public in and for the State of ______________________________ Signature Of Officer Notary Public in and for the State of ______________________________ Signature of Notar y Public Subscribed to me this day of , My Commission Expires Signature of Notar y Public Subscribed to me this day of , My Commission Expires I, , being first duly sworn, state I am a duly elected or appointed officer of the above named corporation. I request a waiver from coverage under the Alaska Workers’ Compensation Act. I am voluntarily, without coercion, signing this waiver request. I understand that I will not qualify for benefits in the event of a work related injury sustained during the performance of my duties as a corporate executive officer. I, , being first duly sworn, state I am a duly elected or appointed officer of the above named corporation. I request a waiver from coverage under the Alaska Workers’ Compensation Act. I am voluntarily, without coercion, signing this waiver request. I understand that I will not qualify for benefits in the event of a work related injury sustained during the performance of my duties as a corporate executive officer. Signature O f Officer Notar y Public in and for the State of ______________________________ Si gnature O f Officer Notar y Public in and for the State of ______________________________ Signature of Notar y Public Subscribed to me this day of , My Commission Expires Signature of Notar y Public Subscribed to me this day of , My Commission Expires