Workers Comp Exclusion Form Template for United States

Create a bespoke document in minutes, or upload and review your own.

4.6 / 5

4.8 / 5

Let's create your Workers Comp Exclusion Form

1. Select your governing law and document type:

2. Enter your key requirements:

3. Create your document to edit, review or download

Get your first 2 documents free

Your data doesn't train Genie's AI

You keep IP ownership of your information

Key Requirements PROMPT example:

Workers Comp Exclusion Form

"I need a Workers Comp Exclusion Form for my California-based LLC where I'm the sole member, to be effective from January 1, 2025, with alternative private health insurance coverage already in place."

Document background

The Workers Comp Exclusion Form is a crucial document for business owners and officers who wish to exclude themselves from workers' compensation coverage in the United States. This form is typically used when individuals have sufficient alternative insurance coverage or when they meet specific state criteria for exemption. The document must adhere to state-specific regulations and usually requires formal filing with state authorities. It includes detailed information about the business, the individual seeking exclusion, and certification of eligibility under applicable state laws.

Suggested Sections

1. Identification Information: Details of the worker seeking exclusion, including name, address, and role in the business

2. Business Information: Legal business name, structure, and relevant registration details

3. Declaration of Election: Formal statement of voluntary election to be excluded from workers' compensation coverage

4. Acknowledgment of Rights: Statement acknowledging understanding of rights being waived and consequences

5. Certification: Sworn statement of eligibility for exclusion under applicable state law

Optional Sections

1. Additional Covered Persons: List of other individuals to be excluded - used when multiple eligible persons from same business are seeking exclusion

2. Limited Time Period: Specification of time period for exclusion if not permanent

3. Insurance Alternative: Details of alternative insurance coverage arrangements

Suggested Schedules

1. Schedule A - Proof of Business Ownership: Documentation proving ownership stake or officer status

2. Schedule B - State-Specific Forms: Required state forms for workers' compensation exclusion

3. Schedule C - Medical Documentation: Any required medical certifications (if applicable by state law)

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Construction
Professional Services
Real Estate
Retail
Technology

Relevant Teams

Human Resources
Legal
Finance
Operations
Risk Management

Relevant Roles

Business Owner
Corporate Officer
Managing Partner
LLC Member
Sole Proprietor

Find the exact document you need

Workers Comp Audit Worksheet

A U.S. regulatory document used to verify workers' compensation insurance premium calculations through payroll and employee classification audit.

How Genie AI reduced drafting time by 75% for a legal firm

Let's create your Workers Comp Exclusion Form

Authors

Alex Denne

Find the exact document you need

Workers Comp Audit Worksheet

Aob Form In Medical Billing

Medicaid Self Pay Agreement

Sgli Form

Medicare Application Form

Health Shield Claim Form

Workers Comp Exclusion Form

Medicare Claim Form

Gap Insurance Cancellation Form

Expired Medicare Card Renewal Form

Insurance Opt Out Form

Waiver Of Subrogation General Liability

General Liability Form

Workers Compensation Waiver Form

Workers Comp Affidavit

Insurance Certificate Of Liability

Workers Comp Exemption Certificate

Health Waiver Form

Driver Exclusion Form

Workers Comp Waiver Form

Waiver Of Subrogation Form

Pet Insurance Claim Form

Health Insurance Waiver Form

Insurance Cancellation Form

Insurance Declaration Form

Download our whitepaper on the future of AI in Legal

Genie’s Security Promise

Your documents are private:

Your documents are protected:

Organizational security

Innovation in privacy:

Want to know more?

Draft quality legal agreements or review documents in 3 minutes

Templates

Commercial

Employment

IP

Administration

Finance

R&D

Industries

Legal Services

Manufacturing

Construction

Solutions

Use Cases

Company Types

Comparisons

Business Categories

Teams

Information