Revocation Of Election Religious Charitable Organization Bring Executives Under NY WC {C-105.4}

C-105.4 - REVOCATION OF ELECTION OF AN INCORPORATED RELIGIOUS, CHARITABLE, EDUCATIONAL, OR U.S. WAR VETERANS ORGANIZATION TO BRING EXECUTIVE OFFICERS UNDER THE COVERAGE OF THE NEW YORK WORKERS' COMPENSATION LAW. This form is used for the revocation of an election made by an incorporated religious, charitable, educational, or U.S. war veterans organization in the State of New York. The purpose of the form is to remove the coverage of executive officers under the New York Workers' Compensation Law. It requires the corporation to provide the necessary information about the corporation itself, including its name, address, and the state under which it is incorporated. Additionally, the form requires the names, titles, and addresses of the executive officers included in the policy. The form should be completed by the corporation's secretary, who certifies the revocation and ensures that copies are filed with the Chair of the Workers' Compensation Board, the insurance carrier named in the form, and each of the executive officers affected. www.FormsWorkflow.com