Worker’s Compensation Insurance Waiver
Insured Name:
Insurer:
Policy No.:
LLC MANAGING MEMBERS – WAIVER OF WORKERS’ COMPENSATION COVERAGE
Pursuant to California Labor Code section 3352(q), I hereby certify, under penalty of perjury, that I am a managing member of the above – named insured. As a managing member, I elect to be excluded from the insured’s workers’ compensation insurance policy with the above – referenced insurer . I understand and agree that this written waiver will be effective upon the date of receipt and acceptance by the limited liability company’s insurer and it shall remain in effect until I provide the insurer with a written withdrawal of this waiver. I understand and agree that by signing this waiver, I will not be entitled to coverage under the insured’s workers’ compensation insurance policy with the above – referenced insurer if an employment – related injury occurs.
_______________________________
Print Managing Member’s Full Name
_______________________________
Title
_______________________________
Managing Member’s Signature
Date: ______________________
Accepted:
_______________________________
Insurance Company
Date: ___________________
NOTE TO EMPLOYER: The exclusion will be endorsed to the policy upon our receipt and acceptance of a signed and properly completed form. The person electing exclusion must sign this form. Company representatives may not sign on behalf of the individual. One exclusion per form. Submit additional forms if needed.