Notice Of Election Of Corporation To Exclude Shareholder Officers From Disability Coverage {DB-212.3}

We, , , and , , certify that we are the two executive officers of the above-named corporation, having been duly appointed by corporate resolution; that we have been the sole owners of all issued and outstanding stock and that each of us owns at least one share of stock of the corporation, and that we hold all of the offices pursuant to paragraph (e) of Section 715 of the Business Corporation Law. Name Title Name Title sinceTAKE NOTICE that under the provisions of Section 212, subdivision 4 of the Disability and Paid Family Leave 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 insurer named above.CERTIFICATIONTHIS ELECTION IS FINAL AND BINDING UPON THE OFFICER(S) NAMED UNTIL REVOKED BY THE CORPORATION.See reverse for Section 212, Subd. 4 (WCL) and Sec. 715, Paragraph (3) of the Business Corporation Law. DB-212.3 (10-17) USE FOR ONE-PERSON CORPORATIONSTATE OF NEW YORK WORKERS' COMPENSATION BOARD Notice of Election of a Corporation which is Required to have Disability and Paid Family Leave Benefits Coverage for its Employees under the Disability and Paid Family Leave Benefits Law to Exclude the Sole Shareholder-Officer or One of Two Shareholder-Officers or Shareholder-Officers of the Corporation from Such Coverage TO (print name and address of insurance carrier here): Corporation Name: Mailing Address: Incorporated Under the Laws of the State of One-person corporation Two-person corporation (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.) Type (check one):Executive Officer(s) to be excluded from policy: I, corporation; that I have been since Title: Name: Name: Title:, certify that I am the sole executive officer of the above-named the sole owner of all issued and outstanding stock of the corporation and hold all the offices pursuant to paragraph (e) of Section 715 of the Business Corporation Law. Signature of Officer Telephone Number Date USE FOR TWO-PERSON CORPORATION Affix corporate seal below, if you have one. If the corporation does not have a seal, check here: Signature of Officer Telephone Number Date Signature of Officer Telephone Number Date American LegalNet, Inc. www.FormsWorkFlow.com DB-212.3 (10-17) REVERSESection 212, Subdivision 4 of the New York Disability and Paid Family Leave Benefits Law (a) 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 executive officers of a corporation who at all times during the period involved between them own all of the issued and outstanding stock of such corporation and holds all such offices provided, however, that each officer must own at least own share of stock and who is the executive officer or who are the executive officers of a corporation having other persons who are employees required to be covered under this article, shall be deemed to be included in the corporation's disability and family leave benefits insurance contract or covered by a certificate of self-insurance or a plan under Section 211 of this article. Such election shall be made by any such corporation filing with the insurance carrier, or the chair of the workers' compensation board in the case of self-insurance, upon a form prescribed by the chair, a notice that the corporation elects to exclude the executive officer or officers of such corporation named in the notice from the coverage of this article. Such election shall be effective with respect to all policies issued to such corporation by such insurance carrier as long as it shall continuously insure the corporation. Such election shall be final and binding upon the executive officer or officers named in the notice until revoked by the corporation. (b) Notwithstanding the definition of "employer" in Section 211 of this article, a sole proprietor, member of a limited liability company or limited liability partnership, or other self-employed person may become a covered employer under this article by complying with the provisions of Subdivision 1 of this Section. Section 715, Paragraph (3) of the Business Corporation Law Any two or more offices may be held by the same person, except the offices of president and secretary. When all of the issued and outstanding stock of the corporation is owned by one person, such person may hold all of any combination of offices. American LegalNet, Inc. www.FormsWorkFlow.com