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Cancellation Of Elective Coverage For Excluded Employments F213-005-000 - Washington
| Cancellation Of Elective Coverage For Excluded Employments Form. This is a Washington form and can be used in Self Insurance Workers Comp . |
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Department of Labor and Industries Olympia WA 98504 CANCELLATION OF ELECTIVE COVERAGE FOR EXCLUDED EMPLOYMENTS The following categories of employment are not included within the mandatory coverage of the Industrial Insurance laws of Washington, Title 51 of the Revised Code of Washington. Please cancel coverage previously elected and indicated with an "X" in the appropriate box(es). 1. 2. 3. 4. 5. 6. 7. 8. 9. DOMESTIC SERVANTS GARDENING, MAINTENANCE, REPAIR, ETC. IN OR ABOUT THE EMPLOYER'S HOME CASUAL EMPLOYMENT SERVICE IN RETURN FOR AID OR SUSTENANCE ONLY MINOR CHILDREN UNDER 18 YEARS OF AGE ON A FAMILY FARM JOCKEY RACING MUSICIANS AND ENTERTAINERS VOLUNTEER LAW ENFORCEMENT OFFICERS (full coverage)(6905) VOLUNTEER WORKERS (Med Aid only) check one or both boxes below Law Enforcement (6906) Other (6901) Community Improvement Project (6901) Project period to 10. COMMUNITY SERVICE WORKERS (7203) 11. NEWSPAPER CARRIERS 12. INSURANCE AGENTS, BROKERS OR SOLICITORS 13. STUDENT VOLUNTEERS K 12 ONLY (Med aid only 6901) 14. Other (please explain) I, the undersigned, certify that I am authorized to execute this Cancellation for Elective Coverage on behalf of this business, public entity or nonprofit organization. Benefits in accordance with Title 51 RCW are to be provided to all persons, now or hereafter working under this optional coverage until 30 days after written notice of cancellation of this election has been received by the department. I shall post notice of this cancellation at least 30 days before the effective date in the work area of the affected worker(s) and shall personally notify other affected worker(s). (RCW 51.12.110) This cancellation will not become effective prior to such time as the Department of Labor and Industries receives this signed notification. Business Name Business Address Applicant's Name Date UBI City Official Position Signature Account ID State ZIP+4 State Fund Accounts: MAIL FORM TO: Note: If your Account ID starts with 700, 701, or 706 EMPLOYER SERVICES Self Insured Accounts: MAIL FORM TO: DEPARTMENT OF LABOR AND INDUSTRIES SELF-INSURANCE SECTION PO BOX 44144 DEPARTMENT OF LABOR AND INDUSTRIES OLYMPIA WA 98504-4144 PO BOX 44891 (360) 902-4817 OLYMPIA WA 98504-4891 (360) 902-6860 F213-005-000 canc of elective coverage for svcs 10-02 American LegalNet, Inc. www.USCourtForms.com
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