Termination of Nonelection of Workers' Compensation or Employers' Liability Coverage

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Type of Entity:

Proprietorship	3
Limited Liability Company	4
Partnership	1

Statement 1 Agreement:

I previously made a nonelection of workers’ compensation or employers’ liability coverage.	8

Statement 2 Agreement:

I understand that by signing this termination, I will terminate the nonelection of coverage.	8

Statement 3 Agreement:

I also understand that after signing and filing this termination, my status will be the same as if the nonelection of coverage had not been made.	8

Statement 4 Agreement:

I also understand that this termination shall not be effective as to any injury sustained or disease incurred less than one week after it is filed.	8

Signed Indication:

Signed	8

Termination Agreement:

The employer terminates the prior nonelection the employers’ liability coverage.	8

Signed indication:

Signed	8

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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:
Statement 4 Agreement:
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:
Signed Indication:
Signed Agreement form 4:
Termination by Employer.
Termination Agreement:
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:
Signed indication:
Form 4 Lower Signed Agreement:

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