New Mexico > Workers Compensation
Revocation Of Prior Election Form - New Mexico
| Revocation Of Prior Election Form Form. This is a New Mexico form and can be used in Workers Compensation . |
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STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION REVOCATION OF PRIOR ELECTION FORM RE: _________________________________________________________________________ (Please clearly print name of business) ( ) Corporation ( ) Partnership ( ) Sole Proprietorship ( ) Limited Liability Company You are notified that the undersigned hereby waives and revokes previously filed forms, as checked below: (check one) () () () Executive Employee Affirmative Election Form (NMSA 1978, §52-1-7) CID Sole Proprietor Affirmative Election Form (NMSA 1978, §52-1-7) Election to Accept Form (NMSA 1978, §52-1-6) Revocation is specifically provided for by NMSA 1978, §52-1-7. The undersigned acknowledges that this revocation shall become effective thirty (30) days after filing the same with the Workers' Compensation Administration. If this revocation revokes a prior election not to be subject to the New Mexico Workers' Compensation Act and the New Mexico Occupational Disease and Disablement Law, the undersigned hereby acknowledges acceptance of the terms, conditions, and provisions of these laws. Signature: _______________________________________ Print name: ______________________________________ Title: ___________________________________________ Business Address: _________________________________ UI Number: ______________________ FEIN Number: ____________________ Phone Number: ___________________ City/State/Zip: ____________________ STATE OF ______________________ ) ) ss. COUNTY OF ____________________ ) SUBSCRIBED AND SWORN OR AFFIRMED to before me on the _______ day of ______________, 20__________ by _________________________________________. ________________________________ Notary Public My commission expires: ___________________ Please retain a copy of this form for your records. 10/4/11 American LegalNet, Inc. www.FormsWorkFlow.com
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