Executive Employee Affirmative Election

STATE OF NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION EXECUTIVE EMPLOYEE AFFIRMATIVE ELECTION PLEASE TYPE OR LEGIBLY PRINT ALL ENTRIES EXCEPT SIGNATURE. I, ___________________________ (Name), am a "worker" as defined in the New Mexico Workers' Compensation Act or the New Mexico Occupational Disease Disablement Law ("the Acts"). I am employed by ______________________________ (Name of corporation), a corporation subject to the provisions of the Acts. Pursuant to NMSA 1978, §52-1-7 or §52-3-6, I affirmatively elect NOT TO ACCEPT the provisions of the Workers' Compensation Act or the New Mexico Occupational Disease Disablement Law. I meet the qualification of §52-1-7 or §52-3-6 as follows: I am the chairperson of the board, president, vice president, secretary, treasurer, or other executive officer of employer corporation; and I own ten percent or more of the outstanding stock of employer corporation. I understand that by making this affirmative election, it applies to all corporations in which I have a financial interest. I further understand that if I wish to revoke my election, I am required by law to file a revocation with my insurance carrier and with the WCA Director's Office, and to mail a copy of the revocation to the board of directors of employer corporation(s). I further agree to notify the WCA Director's Office of any changes in my §52-1-7 or §52-3-6 status. I swear or affirm under penalty of perjury that I have read the foregoing affirmative election in its entirety and understand the information contained therein is true and correct to the best of my knowledge. Signature: ________________________________ Executive Title: ___________________________ UI Number: _______________________ FEIN Number: ____________________ STATE OF ______________________ ) ) ss. COUNTY OF ____________________ ) SUBSCRIBED AND SWORN to before me on the _______ day of ______________, 20__________ by ____________________________________________. ________________________________ Notary Public My commission expires: ___________________ WC/ECB A-I (09/08) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com