Nonelection of Workers' Compensation or Employers' Liability Coverage

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This page shows analysis of submitted data, such as the number of submissions per component value, calculations, and averages. Additional components may be added under the "Add analysis components" fieldset.

Name of Employer:

Left Blank	0
User entered value	2394
Average submission length in words (ex blanks)	3.10

Type of Entity:

Proprietorship	1047
Limited Liability Company	1238
Limited Liability Partnership	40
Partnership	69

Address of Employer's Home Office:

Left Blank	0
User entered value	2394
Average submission length in words (ex blanks)	4.39

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Information About Employer
Name of Employer:
Type of Entity:
Address of Employer's Home Office:
Agreements by Individual.
Statement 1 Agreement:
Statement 2 Agreement:
Statement 3 Agreement:
Understanding Confirmation:
Check Either Alternative (1) or (2):
Individual Information
Date:
Full Name of Individual:
Email:
City of Residence:
County of Residence:
State of Residence:
Full Name of Witness 1:
Full Name of Witness 2:
Signing Indication:
Signed Agreement:
Agreement by Employer.
Check either alternative (1) or (2):
Employer Information
Full Name of Authorized Agent:
Email of Authorized Agent:
Relationship to Employer of Authorized Agent:
City of Residence:
County of Residence:
State of Residence:
Full Name of Witness No. 1:
Full Name of Witness No. 2:
Signing Indication:
Form 3 Lower Signed Agreement:

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