Executive Officers Declaration {LIBC-513}

LIBC-513 -- EXECUTIVE OFFICER’S DECLARATION. This form is used by executive officers of corporations in Pennsylvania who wish to be exempt from coverage under the Pennsylvania Workers’ Compensation Act. It must be submitted along with the corporation’s Application for Executive Officer Exception. Each executive officer with ownership interest must complete a separate declaration, and the combined ownership percentages must total 100%. By signing this form, the officer voluntarily elects not to be considered an employee for workers’ compensation purposes and waives all rights and benefits under the Act. The officer must declare their corporate ownership status—whether in a Subchapter S corporation, Subchapter C corporation (with at least 5% ownership), or a nonprofit corporation served without compensation. The declaration must be signed and verified as true under penalty of law and includes personal identifying information such as name, address, date of birth, social security number, ownership percentage, and contact details. Filing false information can result in civil and criminal penalties. www.FormsWorkflow.com