Corporate Officer Option {WKC-7602}

CORPORATE OFFICER OPTION Dear Employer: Re: Corporate officers are considered employees of the corporation and the co rporation is subject to the Wisconsin subject stockholders. this for 102.04(1)(b) of the Wisconsin Statut es. If a qualified corporation elects to file a Corporate Officer Option Notice, the corporation must complete and return the Corporate Officer Option Notice within 15 days of the date this letter was mailed. A corporation with more than two (2) corporat e officers or any other employee or employees is not eligible to file a ficers, however, a closely held corporation may exclude up to two (2) corporate officers from coverage on their policy. The exclusion must be e xclusion will remain in effect for the policy period. Contact your insurance agent or insurance company regarding this policy endorsement. compensati on insurance policy or the corporation will be considered uninsured and in violation of the Wisconsin twice the amount of premium not paid during the uninsured time period or $750, whichever is greater. Under to a penalty of $100 for each day they are uninsured up to 7 days. If you have qu Programs, at (608) 266 - 1340 or write to P.O. Box 7901, Ma dison, WI 53707 . The Division is located in the GEF 1 State Office Building, Room 161 , 201 East Washington Avenue, Madison. WKC - 7602 (R. 03/2018 ) CNE Department of Workforce Development Bureau of Insurance Programs 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI 53707 Telephone: (608) 266 - 3046 Fax: (608) 266 - 6827 http://dwd.wis consin.gov/wc e - mail: DWDDWC@dwd.wisconsin.gov American LegalNet, Inc. www.FormsWorkFlow.com WCRB: Corporate Officer Option A closely held corporation having no more than two corporate officers and no other employees may elect P.O. Box 7901, Madison, WI 53707 . Our fax number is (608) 266 - 6827. This form must be returned within 15 days. If you have any questions about whether you qualify to file a Corporate Officer Option Notice, please call (608) 266 - 1340 before you complet e and return this form. Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m), Wisconsin Statutes]. Corporate Officer Option Notice Federal Employer Identification Number Corporation Name ( Please Print) Corporation Address City, State, Zip Code cancel this election. The cor poration has no other employees or corporate officers than those listed below. compensation insurance, if required, is twice the amount of premium not paid during an uninsured time period or insurance coverage can be subject to a penalty of $100 for each day they are uninsured up to 7 days. (See sections 1 02.82(2)(a) and 102.82(2)(ag) of the Wisconsin Statutes.) Corporate Officer Name (Please Print) Corporate Officer Name (Please Print) Corporate Officer Signature Corporate Officer Signature Title Title Telephone Number Telephone Number Date Signed Date Signed WKC - 7602 (R. 03/2018 ) CNE American LegalNet, Inc. www.FormsWorkFlow.com