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Nonelection of Workers' Compensation or Employers' Liability Coverage
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Nonelection of Workers' Compensation or Employers' Liability Coverage
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#
Submitted
User
IP address
Name of Employer:
Type of Entity:
Address of Employer's Home Office:
Statement 1 Agreement:
Statement 2 Agreement:
Statement 3 Agreement:
Understanding Confirmation:
Check Either Alternative (1) or (2):
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:
Check either alternative (1) or (2):
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:
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