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Notice For Workers Compensation And Occupational Diseases Coverage 36097 - Indiana

Notice For Workers Compensation And Occupational Diseases Coverage Form. This is a Indiana form and can be used in General Workers Compensation .
 Fillable pdf Last Modified 2/8/2012
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NOTICE FOR WORKERS COMPENSATION AND OCCUPATIONAL DISEASES COVERAGE State Form 36097 (R5 / 9-11) INDIANA WORKERS COMPENSATION BOARD 402 W Washington Street, Room W196 Indianapolis, IN 46204 INSTRUCTIONS: Please type or print. Incomplete or illegible forms will be returned. For current forms, go to www.in.gov/wcb. Pursuant to IC 22-3-6-1(b) and 22-3-2-9, the Indiana Workers Compensation Board is hereby notified that the undersigned applicant does hereby elect to be covered for workers compensation and occupational diseases under the law. STATEMENT OF VOLUNTARY ELECTION [IC 22-3-6-1(b)] Name of applicant Address (number and street, city, state, and ZIP code) Federal Identification number (not Social Security number) I certify that I meet the criteria set out in IC 22-3-6-1 (b) (4), (5) or (9), as selected below: (4) Sole Proprietor (5) Partner (9) Member or Manager of a Limited Liability Company Name of business Address (number and street, city, state, and ZIP code) Name of Insurance carrier Address (number and street, city, state, and ZIP code) Telephone number Nature of business ( ) I certify that I am actually and actively engaged in said business Signature of applicant Printed name I, the undersigned, do elect to be covered by the Workers Compensation and Occupational Diseases coverage until I file a request for cancellation of this election. Date signed (month, day, year) STATEMENT OF VOLUNTARY ELECTION [IC 22-3-2-9] FOR: Farm or Agricultural Employees Household Employees Part-time Volunteer Coaches for non-profit corporation Casual Laborers The undersigned hereby voluntarily elects to be bound by the provisions of the Indiana Workers Compensation and Occupational Diseases acts. I understand that I elect to be covered until I file a request for cancellation of this election. Type of business Sole Proprietor Partnership Corporation LLC ( Other Telephone number Name of Insurance carrier Address (number and street, city, state, and ZIP code) Name of Employer Address (number and street, city, state, and ZIP code) Signature of Employer Name of Agent E-mail address Printed name ) Federal Identification number (not Social Security number) Telephone number ( ) Date signed (month, day, year) Telephone number ( ) American LegalNet, Inc. www.FormsWorkFlow.com
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