Delaware Workers Compensation Election Form
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1DELAWARE WORKERS COMPENSATION ELECTION
1.
CORPORATE EXCLUSION
The undersigned officer of
stipulate that each named
(Firm Name)
officer holds stock in the corporation and that I/we elect to be excluded from coverage under the firm's
workers' compensation policy.
Name
Title
Date
APPROVED:
Date
Firm Name
BY:
Signature
2.
PARTNERS/SOLE PROPRIETORS ELECTION FORM
The undersigned partners/sole proprietors elect coverage under our firm's workers' compensation policy.
I/we understand that this election will result in an increased workers' compensation premium.
Name
Title
Date
APPROVED:
Date
Firm Name
BY:
Signature
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