Maryland Workers' Compensation Commission Exclusion Form

Date Stamp - WCC Use Only
WORKERS’ COMPENSATION COMMISSION
10 East Baltimore Street
Baltimore, Maryland 21202-1641
TEL: (410) 864-5100 or 1 (800) 492-0479
TTD (MD Relay Service): 1(800)735-2258
http://www.wcc.state.md.us
EXCLUSION FORM
Pursuant to the provisions of Labor & Employment Article § 9-206 of the Annotated Code of Maryland,
officers or members of a Farm Corporation, Close Corporation, Professional Corporation, or Limited
Liability Company are covered employees if the officer or member provides a service for monetary
compensation. Such officers or members who satisfy the criteria of Labor & Employment Article
§ 9-206(b) may elect to become excluded from coverage by filing this Exclusion Form with the
Commission.
To exercise this option, any officer or member from the aforementioned types of organizations wishing
to be excluded must sign this document. NOTE: By signing this Exclusion Form below, each
officer or member affirms under the penalties of perjury that the information contained in this
form is true and correct as to that officer or member, to the best of the officer’s or member’s
knowledge, information, and belief.
DATE COMPANY NOTIFIED INSURANCE COMPANY:
DATE:
NAME OF CORPORATION’S INSURANCE COMPANY:
NAME OF COMPANY:
Type of Company (Choose)
Farm Corporation
Close Corporation
Professional Corporation
Limited Liability Company
ADDRESS:
CITY:
STATE:
Typed Name and Title of the Officer
or Member Electing Exclusion
ZIP:
% of
Ownership
IMPORTANT:
Personal Signature
Submit original form to the Workers’ Compensation Commission, a copy to the
insurer of the company/corporation, and keep a copy for your files.
FORM C-16R (11/2002)
CLICK HERE TO CLEAR THE FORM