OFFICER NOTICE OF EXCLUSION

OFFICER NOTICE OF EXCLUSION
GROUP WORKERS' COMPENSATION SELF-INSURANCE FUND

A. Section 161(2) of the Workers' Disability Compensation Act of 1969 states:
A policy or contract of workers' compensation insurance, by endorsement, may exclude coverage as to any 1 or more named partners or the spouse, child, or parent in the employers' family. A person excluded pursuant to this subsection shall not be subject to this act and shall not be considered an employee for purposes of section 115.

B. If an employee wishing to be excluded, is an officer of the corporation, or a member of a Limited Liability Company and owns 10% or more of the stock, a resolution of the Board of Directors allowing this action must also be completed along with section H of this form.
C. Company Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
D. Company Phone Number

Area CodePhone Number
E. Company Federal ID
F. Type of Business

Sole ProprietorshipPartnershipCorporationLimited Liability Company
G. PERSONS SIGNING BELOW CERTIFY THAT THEY ARE ELGIBLE TO BE EXCLUDED UNDER THE MICHIGAN WORKERS' DISABILITY COMPENSATION ACT. EACH PERSON SIGNING THIS FORM VOLUNTARILY ELECTS TO BE EXCLUDED FROM BEING CONSIDERED AN EMPLOYEE UNDER THE ACT AND COVERAGE FROM THIS GROUP WORKERS' COMPENSATION SELF-INSURANCE FUND FOR THE CURRENT POLICY PERIOD.
H.
1. Name Of Employee

First NameLast Name
Choose one.

Corporate OfficerPartnerSpouseChildParent
Title
Signature

Clear
Social Security Number
2. Name Of Employee

First NameLast Name
Choose one.

Corporate OfficerPartnerSpouseChildParent
Title
Signature

Clear
Social Security Number
3. Name Of Employee

First NameLast Name
Title
Choose one.

Corporate OfficerPartnerSpouseChildParent
Signature

Clear
Social Security Number
4. Name Of Employee

First NameLast Name
Choose one.

Corporate OfficerPartnerSpouseChildParent
Title
Signature

Clear
Social Security Number
5. Name Of Employee

First NameLast Name
Choose one.

Corporate OfficerPartnerSpouseChildParent
Title
Signature

Clear
Social Security Number
COMPLETED BY:
Date

MonthDayYear
Date
Should be Empty: