Notice For Workers Compensation And Occupational Diseases Coverage {36097}

Reset Form NOTICE FOR WORKER'S COMPENSATION AND OCCUPATIONAL DISEASES COVERAGE State Form 36097 (R8 / 6-15) Mail to: Worker's Compensation Board of Indiana, 402 W. Washington St., Room W196, Indianapolis, IN 46204-2753. APPLICANT INFORMATION Name of employer Address (number and street, city, state, and ZIP code) Name of insurer Name of applicant Insurer policy number Telephone number Policy effective dates (mm/dd/yy) Federal Identification number Start: E-mail address End: ( ) STATEMENT OF VOLUNTARY EXCLUSION (IC 22-3-6-1 (b)(1) / IC 22-3-7-9 (b)(9)) An officer of a corporation may not be considered to be excluded as an employee under IC 22-3-2 through IC 22-3-6 until the notice is received by the insurance carrier and the board. I am an officer with an ownership interest in the above named corporation, and I elect not to be an employee; hereby excluding myself from workers compensation coverage. Signature of corporate officer Date (mm/dd/yyyy) STATEMENT OF VOLUNTARY ELECTION (IC 22-3-6-1 (b)) (2) I am the executive officer in the above named municipal corporation or other governmental subdivision or of a charitable, religious, educational or other nonprofit corporation and am electing worker's compensation coverage. (4) I am the sole proprietor in the above named entity and am electing worker's compensation coverage. (5) I am a partner in the above named entity and am electing worker's compensation coverage. (8) I am an owner-operator that provides a motor vehicle and the services of a driver under a written contract that is subject to IC 8-2.1-24-23, 45 IAC 16-1-13, or 49 CFR 376 to a motor carrier and am electing worker's compensation coverage. (9) I am a member or manager in the above named limited liability company and am electing worker's compensation coverage. STATEMENT OF VOLUNTARY ELECTION (IC 22-3-2-9) The notice of acceptance referred to in subsection 22-3-2-9(b) shall be given thirty (30) days prior to any accident resulting in injury or death, provided that if any such injury occurred less than thirty (30) days after the date of employment, notice of acceptance given at the time of employment shall be sufficient notice thereof. A copy of the notice in prescribed form shall also be filed with the Worker's Compensation Board, within five (5) days after its service in such manner upon the employee or employer. (1) I am the employer of casual laborers and hereby elect to provide worker's compensation coverage. (2) I am the employer of farm or agricultural employees and hereby elect to provide worker's compensation coverage. (3) I am the employer of household employees and hereby elect to provide worker's compensation coverage. (4) I am the employer of part-time volunteer coaches for a nonprofit corporation and hereby elect to provide worker's compensation coverage. STATEMENT OF VOLUNTARY ELECTION (IC 22-3-2-5) I am the owner or representative of a state, county, township, city, town, school city, school town, school township, other municipal corporation, state institution, state board, state commission, bank, trust company or building and loan association and am electing worker's compensation coverage. STATEMENT OF VOLUNTARY ELECTION (IC 22-3-2-2) I am the employer of members of a fire department or police department of a municipal corporation, who are also members of a firefighters' pension fund or a police officers' pension fund; and hereby elect to purchase and procure worker's compensation insurance to insure said employees with respect to medical benefits. I am the employer of "rostered volunteers"; and hereby elect to cover said volunteers under the medical treatment provisions of the worker's compensation act. Signature of employer or authorized agent Date (mm/dd/yyyy) American LegalNet, Inc. www.FormsWorkFlow.com