Exclusion {16}

MARYLAND WORKERS' COMPENSATION COMMISSION EXCLUSION FORM INSTRUCTIONS: Pursuant to Labor & Employment Article §9-206, Annotated Code of Maryland, officers or members of certain business entities may elect to be exempt from workers' compensation insurance coverage by filing this Exclusion Form with the Commission. To exercise this option, the officer or member making the election must sign this document. Submit the original form to the Workers' Compensation Commission, a copy to the insurer of the company/corporation, and keep a copy for your files. Company Name: ______________________________________________________________________ Address: ____________________________________________________________________________ City: _____________________ State: ___________ ZIP _______________________ Type of Company: ___ Close Corporation ___ Professional Corporation ___ General Corporation ___ Limited Liability Company ___ Farm Corporation Insurance Company Name: _____________________________________________________________ Date Insurance Company Notified: _________________ Typed Name and Title of the Officer or Member Electing Exclusion ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ % of Ownership ________ ________ ________ ________ ________ Personal Signature ___________________ ___________________ ___________________ ___________________ ___________________ NOTE: By signing this Exclusion Form, each officer or member affirms under the penalties of perjury that the information contained in this form is true and correct as to that officer or member, to the best of the officer's or member's knowledge, information, and belief. 10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us Form IC-16 (01/11) American LegalNet, Inc. www.FormsWorkFlow.com