Application For Waiver {WCB-2C}

APPLICATION FOR WAIVER STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027 TEL: (207) 287-3751 FAX: (207) 287-5413 WAIVERS ARE NO T V ALID UNTIL APPROVED BY THE BOARD APPLICANT-EMPLOYEE NAME: STREET: CITY, STATE, ZIP: APPLICANT PHONE #: NAME: STREET: BUSINESS - EMPLOYER CITY, STATE, ZIP: EMPLOYER PHONE #: EMPLOYER FEIN #: I am employed by the above-named employer which is a (check one): SOLE PROPRIETOR PARTNERSHIP LIMITED LIABILITY COMPANY CORPORATION/S-CORP PROFESSIONAL CORPORATION And (select the correct option under I, II or III ): I. The Applicant is the (check one): PARENT SPOUSE DOMESTIC PARTNER CHILD of the above-named Sole Proprietor, or Partner or Member of a Limited Liability Company. II. The Applicant is the (check one) named corporation OR bona fide owner of at least 20% of the outstanding voting stock of the abovePARENT SPOUSE DOMESTIC PARTNER CHILD of a bona fide the (check one): owner. Number of Voting Stock Issued by Employer Number of Voting Stock Owned by Applicant (actual number--not percentage) (actual number--not percentage) III. The Applicant is a (check one) shareholder of the above-named professional corporation OR the (check one): PARENT SPOUSE DOMESTIC PARTNER CHILD of a shareholder of the above-named professional corporation. I hereby waive all benefits and privileges provided by the Maine Workers' Compensation Act pursuant to 39-A M.R.S.A. §102(11) (A) (4) and (5). I certify that the foregoing information is truthful and accurate, and that this waiver is not a prerequisite condition to employment. I understand that if this information is found to be intentionally misleading or fraudulent, or if the information changes, this waiver may be nullified. I agree to notify the Workers' Compensation Board of any changes in this information. APPLICANT SIGNATURE DATE NOTE: ANY PERSON MAY REVOKE OR RESCIND THAT PERSON'S WAIVER UPON 30 DAYS WRITTEN NOTICE TO THE BOARD AND THAT PERSON'S EMPLOYER. The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers' Compensation Board. Telephone: (888) 801-9087 or TTY Maine Relay 711. American LegalNet, Inc. WCB-2C (eff. 1/1/13) www.FormsWorkFlow.com