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Inclusion Form - Sole Proprietors Or Partners Election Form C-15R - Maryland

Inclusion Form - Sole Proprietors Or Partners Election Form Form. This is a Maryland form and can be used in Financial Reporting Workers Compensation .
 Fillable pdf Last Modified 11/20/2003
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WORKERS COMPENSATION COMMISSION Date Stamp WCC Use 10 East Baltimore Street Only Baltimore, Maryland 21202-1641 TE L: (410) 864-5100 or 1(800) 492-0479 TTD (MD Relay Service) : 1(800) 735-2258 http://www.wcc.state.md.us INCLUSION FORM SOLE PROPRIETORS/ PARTNERS ELECTION FORM Pursuant to the provisions of Title 9, 9-219 and 9-227 of the Annotated Code of Maryland, sole proprietors and partners are excluded from coverage under the Workers Compensation Act of Maryland. Such persons may elect to become covered employees under the Workers Compensation Act of Maryland. To exercise this option, any sole proprietor or partner wishing to be a covered employee must sign this document. IMPORTANT: Submit original form to the Workers Compensation Commission, a copy to the insurer, and keep a copy for your files. Unless otherwise agreed upon, this election will be effective upon the date of receipt by the Workers Compensation Commission. CURRENT DATE: DATE INSURANCE COMPANY WAS NOTIFIED: NAME OF INSURANCE COMPANY: COMPANY NAME: ADDRESS: CITY: STATE: ZIP: Social Security Name and Title of Person Electing Coverage Personal Signature Number FORM C-15R (Rev. 11/2002)
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