Declaration Of Exemption {IC-53}

Effective July 1, 1997, the Idaho legislature amended the Workers Compensation Law toallow a family member employee of a sole proprietorship who is related to the sole proprietoremployer within the first degree of consanguinity, and who is not residing in the household ofthe sole proprietor employer, to file an election for exemption from workers compensationinsurance coverage. To qualify for the exemption, the following conditions must be met: 1. The employer must be a sole proprietorship. 2. The family member must not dwell in the same household as the employer. NOTE: Family members of a sole proprietor employer dwelling in the household of the sole proprietor are already exempt under Section 72-212(4). 3. The relationship between the employee and employer must be within the first degree of consanguinity. The attached chart identifies the relationships eligible for exemption. 4. The family member must file a written declaration with the Industrial Commission and the declaration must be approved by the Industrial Commission. INSTRUCTIONS FOR COMPLETING IC53 ELECTION FOR EXEMPTION FORM1. Complete all of the information in the employee and employer sections. If the employer does not carry workers compensation insurance, indicate "none" in the space provided for the name of the insurance company.2. Check the appropriate box at the bottom of the form designating the form as either an election for exemption or a revocation of a previously filed election for exemption.3. Both the employee and employer must sign at the bottom of the form where indicated. A separate IC53 Election for Exemption form must be filed for each family member requesting an exemption.4. Mail the original and one copy of the IC53 Election for Exemption to the Idaho Industrial Commission at the following address: Employer Compliance Department P.O. Box 83720 Boise, ID 83720-0041 or, you may fax the form to the Employer Compliance Department at (208) 334-5145.<<<<<<<<<********>>>>>>>>>>>>> 25. If the employer carries workers compensation insurance, it is the employers responsibility to send a copy of the IC53 Election for Exemption to the insurance company. 6. The effective date of the exemption will be the date the properly completed form is received by the Industrial Commission.7. Once the form is reviewed and approved by the Industrial Commission, a copy will be mailed to the employee claiming the exemption.8. The exemption will remain in effect until (1) a revocation of exemption form is filed with the Industrial Commission; (2) termination of employment with the designated employer; or (3) upon the death of the employee, whichever occurs first. If a break in service with the designated employer occurs for a period of 365 days or less, the exemption remains in effect until revoked or upon the death of the employee.<<<<<<<<<********>>>>>>>>>>>>> 3 DECLARATION UNDER IDAHO CODE 72-212(5) THE VALIDITY OF THIS DECLARATION IS SUBJECT TO THE REQUIREMENTS OF IDAHO CODE 72-212(5). To be completed by employee. Please type or print. EMPLOYEE Employee Name: _______________________________________________________________________ Mailing Address: _______________________________________________________________________ Street Address or Post Office Box City State Zip Code Physical Address: _______________________________________________________________________ Street Address City State Zip Code Telephone Number: _________________________ Social Security Number: ______________________ Relationship to Employer: ________________________________________________________________ To be completed by employer. Please type or print.EMPLOYER Name of Sole Proprietor Employer: _______________________________________________________ Business Name, If Any: _________________________________________________________________ Federal Employer ID #: _________________________________ Telephone #: ___________________ Physical Location of Business: ____________________________________________________________ Street City State Zip Code Mailing Address of Business: _____________________________________________________________ Street or Post Office Box City State Zip Code Home Address of Employer: _____________________________________________________________ Street City State Zip Code Employer Information Provided By:_______________________________________________________ Please type or print name If employer has a workers compensation insurance policy, complete the following: Insurance Company: ____________________________________________________________________ Policy #: _____________________________________ Eff. Date: ______________________________ CHECK ONE OF THE FOLLOWING: GG I hereby exclude myself from coverage under the Idaho Workers Compensation Law and understand that I am not eligible for workers compensation insurance benefits until this declaration is revoked. GG I hereby revoke the election of exemption previously filed with the Industrial Commission. By my signature I certify that the foregoing is true and correct, to the best of my knowledge. Signature of Employee: _______________________________________ Date: _______________________ Signature of Employer: _______________________________________ Date: _______________________ Form IC53 - Revised 9/16/97