New Mexico > Workers Compensation
Election To Accept (Employers Election To Accept WC Coverage) - New Mexico
| Election To Accept (Employers Election To Accept WC Coverage) 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 ELECTION TO ACCEPT PLEASE TYPE OR LEGIBLY PRINT ALL ENTRIES EXEPT SIGNATURE. This is to certify that I, _______________________________, of ________________________, (Name of Business/DBA(s)) am an employer in the State of New Mexico, who, pursuant to NMSA 1978, ยง52-1-6, ACCEPTS the provisions of the New Mexico Workers' Compensation Act and Occupational Disease Disablement Law. I hereby elect to be included in the definition of employer and employee for the purpose of entitlement to the benefits under the law. Signature: ______________________________________ Title: __________________________________________ Date: _____________________ Unemployment Insurance Number: ___________________________ Federal Employer Identification Number: __________________________ ) ) ss. COUNTY OF ____________________ ) SUBSCRIBED AND SWORN to before me on the _______ day of ______________, 20__________ by ____________________________________________. STATE OF ___________________ ________________________________ Notary Public My commission expires: ____________________ WC/ECB A-II (9/08) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com
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