Inclusion Form - Sole Proprietors Or Partners Election Form {C-15R}

WORKERS' COMPENSATION COMMISSION 10 East Baltimore Street Baltimore, Maryland 21202-1641 TEL: (410) 864-5100 or 1(800) 492-0479 TTD (MD Relay Service) : 1(800) 735-2258 http://www.wcc.state.md.us Date Stamp ­ WCC Use Only INCLUSION FORM SOLE PROPRIETORS/ PARTNERS ELECTION FORM Pursuant to the provisions of § 9-219 and § 9-227 of the Labor and Employment Article, Annotated Code of Maryland, sole proprietors and partners are excluded from coverage under the Workers' Compensation Act of Maryland. Such persons may elect to become covered employees under the Workers' Compensation Act of Maryland. To exercise this option, any sole proprietor or partner wishing to be a covered employee must complete and sign this document. IMPORTANT: Submit original form to the Workers' Compensation Commission, a copy to the insurer, and keep a copy for your files. Unless otherwise agreed upon, this election will be effective upon the date of receipt by the Workers' Compensation Commission. CURRENT DATE: NAME OF INSURANCE COMPANY: DATE INSURANCE COMPANY WAS NOTIFIED: COMPANY NAME: ADDRESS: CITY: Name and Title of Person Electing Coverage STATE: Social Security Number ZIP: Personal Signature FORM C-15R (Rev. 07/2015) American LegalNet, Inc. www.FormsWorkFlow.com