Election Of Coverage {IC-52}

IC52 ELECTION OF COVERAGE The undersigned hereby notifies the Industrial Commission of the following: Household domestic service Casual employment Employment of outworkers Employment of members of an employer's family dwelling in his household. (Applies only to sole-proprietorships and single member limited liability companies that are taxed as a sole-proprietorship) Employment as the owner of a sole proprietorship Employment of a working member of a partnership or a limited liability company (Circle either partnership or Limited Liability Company; if the election applies only to certain partners/members, name the covered partners/members.) Employment of an officer of a corporation who at all times during the period involved owns not less than ten percent (10%) of all of the issued and outstanding voting stock of the corporation and, if the corporation has directors, is also a director thereof (If the election applies only to certain corporate officers, name the covered officers) Employment for which a rule of liability for injury, occupational disease, or death is provided by the laws of the United States Pilots of agricultural spraying or dusting planes Associate real estate brokers and real estate salesmen paid solely by commission Volunteer ski patrollers Officials of athletic contests involving secondary schools (Name of Insurance Company) Policy Number Insured Name Effective Date of Election/Revocation (Signature of authorized representative) (Employer's signature) Check the appropriate box Election Revocation of Election American LegalNet, Inc. www.FormsWorkFlow.com