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The Maryland Exclusion Form is an important document for business owners and certain officers looking to opt out of workers' compensation insurance coverage. This form allows specific members of business entities, such as close corporations, general corporations, and limited liability companies, to formally declare their exemption under Maryland law. To initiate this process, the elected officer or member must complete the form, which includes essential details like the company name, address, and type of business entity. Once filled out, the form must be submitted to the Workers' Compensation Commission, as well as provided to the company's insurance provider. Additionally, it is crucial for the individual electing the exclusion to retain a copy for their records. Each signatory affirms the accuracy of the information provided, acknowledging the legal implications of their declaration. Understanding the nuances of this form can help business owners make informed decisions about their workers' compensation needs while ensuring compliance with state regulations.
Maryland Exclusion Preview
WORKERS’ COMPENSATION COMMISSION
EXCLUSION FORM
INSTRUCTIONS: Pursuant to Labor & Employment Article
Company Name: ______________________________________________________________________
Address: ____________________________________________________________________________
City: _____________________ |
State: ___________ |
ZIP _______________________ |
|
Type of Company: |
|
|
|
___ Close Corporation |
___ General Corporation |
___ Farm Corporation |
|
___ Professional Corporation |
___ Limited Liability Company |
|
|
Insurance Company Name: _____________________________________________________________
Date Insurance Company Notified:_________________
Typed Name and Title of the Officer |
% of |
Personal |
or Member Electing Exclusion |
Ownership |
Signature |
____________________________________ |
________ |
___________________ |
____________________________________ |
________ |
___________________ |
____________________________________ |
________ |
___________________ |
____________________________________ |
________ |
___________________ |
____________________________________ |
________ |
___________________ |
NOTE: By signing this Exclusion Form, each officer or member affirms under the penalties of perjury that the information contained in this form is true and correct as to that officer or member, to the best of the officer’s or member’s knowledge, information, and belief.
10 East Baltimore Street Baltimore, Maryland
Form
Form Attributes
| Fact Name | Description |
|---|---|
| Governing Law | The Maryland Exclusion Form is governed by Labor & Employment Article §9-206, Annotated Code of Maryland. |
| Eligibility | Officers or members of certain business entities can elect to be exempt from workers' compensation insurance coverage. |
| Filing Requirement | The Exclusion Form must be filed with the Workers’ Compensation Commission to exercise the exemption option. |
| Notification | A copy of the Exclusion Form must be submitted to the insurer of the company or corporation. |
| Record Keeping | Each officer or member must keep a copy of the Exclusion Form for their records. |
| Types of Companies | The form is applicable to close corporations, general corporations, farm corporations, professional corporations, and limited liability companies. |
| Signature Requirement | The officer or member electing exclusion must sign the form, affirming the accuracy of the information provided. |
| Penalties for False Information | By signing the form, officers or members affirm under penalties of perjury that the information is true and correct. |
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