Nonelection of Workers' Compensation or Employers' Liability Coverage

Primary tabs

Secondary tabs

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 Blank0
User entered value1522
Average submission length in words (ex blanks)3.11

Date:

Left Blank0
User entered value1522

Full Name of Individual:

Left Blank0
User entered value1522
Average submission length in words (ex blanks)2.39

City of Residence:

Left Blank0
User entered value1522
Average submission length in words (ex blanks)1.41

County of Residence:

Left Blank0
User entered value1522
Average submission length in words (ex blanks)1.10

State of Residence:

Left Blank0
User entered value1522
Average submission length in words (ex blanks)1.14

Full Name of Witness 1:

Left Blank0
User entered value1522
Average submission length in words (ex blanks)2.18

Full Name of Witness 2:

Left Blank0
User entered value1522
Average submission length in words (ex blanks)2.17

Signing Indication:

Signed1522

Check either alternative (1) or (2):

(1) The employer does not elect the employers’ liability coverage.1443
(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.79

Full Name of Authorized Agent:

Left Blank0
User entered value1522
Average submission length in words (ex blanks)2.40

Relationship to Employer of Authorized Agent:

Left Blank0
User entered value1522
Average submission length in words (ex blanks)1.26

City of Residence:

Left Blank0
User entered value1522
Average submission length in words (ex blanks)1.40

County of Residence:

Left Blank0
User entered value1522
Average submission length in words (ex blanks)1.10

State of Residence:

Left Blank0
User entered value1522
Average submission length in words (ex blanks)1.13

Full Name of Witness No. 1:

Left Blank0
User entered value1522
Average submission length in words (ex blanks)2.18

Full Name of Witness No. 2:

Left Blank0
User entered value1522
Average submission length in words (ex blanks)2.17

Signing Indication:

Signed1522