New York > Workers Compensation
Notice Of Election Of Corporation To Exclude Shareholder Officers From Disability Coverage DB-212.3 - New York
| Notice Of Election Of Corporation To Exclude Shareholder Officers From Disability Coverage Form. This is a New York form and can be used in Workers Compensation . |
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COURT .NTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .State of New York .... .. .... : Index No. WORKERS' COMPENSATION BOARD : NOTICE OF ELECTION OF A CORPORATION WHICHNo.REQUIRED TO HAVE DISABILITY Calendar IS BENEFITS COVERAGE FOR ITS EMPLOYEES UNDER THE DISABILITY BENEFITS LAW TO : EXCLUDE THE SOLE SHAREHOLDER-OFFICER OR ONE OF THE TWO OR BOTH JUDICIAL SUBPOENA Plaintiff(s) SHAREHOLDER-OFFICERS OF THE CORPORATION FROM SUCH COVERAGE -against: To: (Print name and address of insurance carrier here.) TAKE NOTICE that under the provisions of Section 212, : subdivision 4 of the Disability Benefits Law as amended, the corporation named below elects to exclude the executive officer(s) named below from coverage under the New York State Workers' : Compensation Law with respect to all the policies issued to the corporation by the insurance carrier named above. Defendant(s) : . . . . Name. of. Corporation. ____________________________________________________________________________________ .... . ......... ............................. Address of Corporation __________________________________________________________________________________ Incorporated Under the Laws of the State PEOPLE OF THE STATE OF NEW YORK of __________________________________________________________________ Type: One-person corp. Two-person corp. (A two-person corporation may elect to exclude one or both executive officers, provided that between them they own all the stock in the corporation, and that each officer owns at least one share of stock.) Executive Officer(s) to be ETINGS: excluded from policy 1. Name ______________________________________ Title ________________________________ 2. Name ______________________________________ Title ________________________________ WE COMMAND YOU, that all business and excuses CERTIFICATION and each of you attend before being laid aside, you , onorable at the Court USE FOR ONE-PERSON CORPORATION located at nty of I, _________________________________________________, certify that I am the sole executive officer of the above-named om , on the day Name of , 20 , at o'clock in the noon, and at any recessed journed date, to testify havegive evidence as a witness in this action on the part all issued and outstanding stock of the corporation corporation; that I and been since __________________the sole owner of of the Date arty on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a lt of your failure to comply. and hold all the offices pursuant to paragraph (e) of Section 715 of the Business Corporation Law. (Affix corporate seal below, if you have one.) ________________________________________________ ______________________ __________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Signature of Officer Date Telephone No. Witness, Honorable Name , one of the Justices of the Title Name rt in ___________________________________ certify that we are the two executive officers of the above-named corporation, County, day of , 20 Title Date USE FOR TWO-PERSON CORPORATION We, _______________________________ , _____________________________ and _______________________________, having been duly appointed by corporate resolution; that we have been since _____________________ the sole owners of all issued and outstanding stock and that each of us owns at least one share of stock of name below) (Attorney must sign above and type the corporation, and that we hold all of the offices pursuant to paragraph (e) of Section 715 of the Business Corporation Law. (Affix corporate seal below, if you have one.) ________________________________________________ ______________________ __________________________ Signature of Officer Date Telephone No. Attorney(s) for ________________________________________________ ______________________ __________________________ Signature of Officer Date Telephone No. THIS ELECTION IS FINAL AND BINDING UPON THE OFFICER(S) NAMED UNTIL REVOKED BY THE CORPORATION. Office and P.O. Address CORPORATE SEAL* Telephone No.: *If the corporation does not have a seal, check here q Facsimile No.: E-Mail Address: See reverse side for relevant portions of Section 212, Mobile Tel. No.: Sec. 715, Par. (e) of the Business Corporation Law. subd. 4 (DBL) and DB-212.3 (1-04) American LegalNet, Inc. www.USCourtForms.com www.wcb.state.ny.us COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Plaintiff(s) : Index No. Calendar No. JUDICIAL SUBPOENA Section 212, Subdivision 4 of the -against: New York Disability Benefits Law : An executive officer of a corporation who at all times during the period involved owns all : of the issued and outstanding stock of the corporation and holds all of the offices pursuant to paragraph (e) of section 715 of the business corporation law or two Defendant(s) : . . . . . . . . . . . officers . of .a .corporation. who . at .all .times. during the period involved between executive . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . them own all of the issued and outstanding stock of such corporation and hold all such offices provided, however, that each officer must own at least one share of stock and THE PEOPLE OF THE STATE OFor who are the executive officers of a corporation having who is the executive officer NEW YORK other persons who are employees required to be covered under this article, shall be TO deemed to be included in the corporation's disability benefits insurance contract or covered by a certificate of self-insurance or a plan under section two hundred eleven of this article, unless the officer or officers elect to be excluded from the coverage of this article. Such election shall be made by any such corporation filing with the insurance GREETINGS: carrier, or the chair of the workers' compensation board in the case of self insurance, upon a WE COMMAND YOU,the chairman, a notice that thelaid aside, you and each ofexclude before form prescribed by that all business and excuses being corporation elects to you attend , the Honorable at the Court the executive officer or officers of such corporation named in the notice from the located at County of coverage of this article. day of election shall be at Such effective with in the respect to all and at any recessed policies in room , on the , 20 , o'clock noon, issued to such
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