Application For Executive Officer Exception {LIBC-509}

LIBC-509 - APPLICATION FOR EXECUTIVE OFFICER EXCEPTION. If not filing electronically, submit one original application for the corporation along with an Executive Officer’s Declaration for every officer having an ownership interest. The total ownership interest of all declarations combined must equal 100 percent. If the corporation has workers’ compensation insurance, all forms must be submitted directly to the insurance carrier. If not, submit all original forms to: Bureau of Workers’ Compensation, Compliance Section, 651 Boas Street, 8th Floor, Harrisburg, PA 17121-0750. www.FormsWorkflow.com