Indiana Notice For Workers' Compensation And Occupational Disease Coverage

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NOTICE FOR WORKER’S COMPENSATION
AND OCCUPATIONAL DISEASES COVERAGE
INDIANA WORKER’S COMPENSATION BOARD
402 W Washington Street, Room W196
Indianapolis, IN 46204
State Form 36097 (R5 / 9-11)
INSTRUCTIONS: Please type or print. Incomplete or illegible forms will be returned. For current forms, go to www.in.gov/wcb.
Pursuant to IC 22-3-6-1(b) and 22-3-2-9, the Indiana Worker’s Compensation Board is hereby notified that the undersigned applicant
does hereby elect to be covered for worker’s compensation and occupational diseases under the law.
STATEMENT OF VOLUNTARY ELECTION [IC 22-3-6-1(b)]
Federal Identification number (not Social Security number)
Name of applicant
Address (number and street, city, state, and ZIP code)
I certify that I meet the criteria set out in IC 22-3-6-1 (b) (4), (5) or (9), as selected below:
(4) Sole Proprietor
(5) Partner
(9) Member or Manager of a Limited Liability Company
Name of business
Nature of business
Address (number and street, city, state, and ZIP code)
Telephone number
Name of Insurance carrier
(
)
Address (number and street, city, state, and ZIP code)
I certify that I am actually and actively engaged in said business
Signature of applicant
I, the undersigned, do elect to be covered by the Worker’s
Compensation and Occupational Diseases coverage until I file
a request for cancellation of this election.
Printed name
Date signed (month, day, year)
STATEMENT OF VOLUNTARY ELECTION [IC 22-3-2-9]
FOR:
Farm or Agricultural Employees
Household Employees
Part-time Volunteer Coaches for non-profit corporation
Casual Laborers
The undersigned hereby voluntarily elects to be bound by the provisions of the Indiana Worker’s Compensation and Occupational Diseases
acts. I understand that I elect to be covered until I file a request for cancellation of this election.
Type of business
Sole Proprietor
Partnership
Corporation
Name of Insurance carrier
LLC
Other
Telephone number
(
)
Address (number and street, city, state, and ZIP code)
Name of Employer
Federal Identification number (not Social Security
number)
Telephone number
(
)
Address (number and street, city, state, and ZIP code)
Signature of Employer
Name of Agent
E-mail address
Printed name
Date signed (month, day, year)
Telephone number
(
)