Form SF0137 "Election to Exclude Certain Relatives of Managers of a Limited Liability Company" - Minnesota

What Is Form SF0137?

This is a legal form that was released by the Minnesota Department of Labor and Industry - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2016;
  • The latest edition provided by the Minnesota Department of Labor and Industry;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SF0137 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Labor and Industry.

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Download Form SF0137 "Election to Exclude Certain Relatives of Managers of a Limited Liability Company" - Minnesota

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Minnesota Department of Labor and Industry
RESET
Workers’ Compensation Division – SCF
P.O. Box 64229
St. Paul, MN 55164-0229
Election to Exclude Certain Relatives of
Managers of a Limited Liability Company
Minnesota Statutes § 176.041, subd. 1(20)
Use this form to exclude (omit) from workers’ compensation coverage certain employees who are related within the third
degree of kindred to a manager of a limited liability company (LLC) who owns at least 25 percent membership in the LLC.
A manager of the LLC must complete and sign this form. A chart showing relatives within the third degree of kindred is
online at
www.dli.mn.gov/WC/Pdf/infosheet_3rd_degree_kindred.pdf.
You do not need to file this form if you only intend to exclude the spouse, parent or children of a manager who owns at
least a 25 percent membership in the LLC – they are automatically excluded from coverage.
Section 1. Information about the limited liability company
Legal name of the LLC exactly as registered with the Minnesota Secretary of State
Phone number
Mailing address
City
State
ZIP code
Section 2. Eligibility
A. Is this LLC owned by 10 or fewer members?
Yes
No
B. Did this LLC have less than 22,880 hours of payroll in the preceding calendar year?
Yes
No
C. Is this LLC currently registered as active with the Minnesota Secretary of State?
Yes
No
If you answered “no” to any of the questions above, you are not eligible to exclude relatives other than the spouse, parent
or children of the manager from workers’ compensation coverage. Contact your insurance agent to make sure they are
covered.
If you answered “yes” to all of the questions in Section 2, complete Sections 3 through 5.
Section 3. Membership interest owned by the manager(s) of the LLC
List the names of all managers who own at least 25 percent membership interest
Percent of the LLC membership interest
in the LLC
owned by this manager
(over)
SF0137 1/16
Minnesota Department of Labor and Industry
RESET
Workers’ Compensation Division – SCF
P.O. Box 64229
St. Paul, MN 55164-0229
Election to Exclude Certain Relatives of
Managers of a Limited Liability Company
Minnesota Statutes § 176.041, subd. 1(20)
Use this form to exclude (omit) from workers’ compensation coverage certain employees who are related within the third
degree of kindred to a manager of a limited liability company (LLC) who owns at least 25 percent membership in the LLC.
A manager of the LLC must complete and sign this form. A chart showing relatives within the third degree of kindred is
online at
www.dli.mn.gov/WC/Pdf/infosheet_3rd_degree_kindred.pdf.
You do not need to file this form if you only intend to exclude the spouse, parent or children of a manager who owns at
least a 25 percent membership in the LLC – they are automatically excluded from coverage.
Section 1. Information about the limited liability company
Legal name of the LLC exactly as registered with the Minnesota Secretary of State
Phone number
Mailing address
City
State
ZIP code
Section 2. Eligibility
A. Is this LLC owned by 10 or fewer members?
Yes
No
B. Did this LLC have less than 22,880 hours of payroll in the preceding calendar year?
Yes
No
C. Is this LLC currently registered as active with the Minnesota Secretary of State?
Yes
No
If you answered “no” to any of the questions above, you are not eligible to exclude relatives other than the spouse, parent
or children of the manager from workers’ compensation coverage. Contact your insurance agent to make sure they are
covered.
If you answered “yes” to all of the questions in Section 2, complete Sections 3 through 5.
Section 3. Membership interest owned by the manager(s) of the LLC
List the names of all managers who own at least 25 percent membership interest
Percent of the LLC membership interest
in the LLC
owned by this manager
(over)
SF0137 1/16
Section 4. Relatives to be excluded from workers’ compensation coverage
List the relatives to be excluded from workers’ compensation coverage and their relationship to one of the managers listed in
Section 3. (Attach an additional sheet if necessary.)
Name of the relative to be excluded
Name of the related LLC manager
Relationship to the manager
Section 5. Certification
By signing this form I certify that all information provided is complete and accurate to the best of my knowledge and that I
have the authority to sign this form for the LLC named in Section 1.
Manager’s name (print or type)
Phone number
Signature
Date signed
Have the relatives listed in Section 4 been notified that this form to exclude them
Yes
No
from workers’ compensation coverage is being filed?
yes
_____ no.
Submit a copy of this form to your workers' compensation insurance company, if any. If you change insurance companies,
submit a copy of this form to the new insurance company.
Refile this form with the Department of Labor and Industry (DLI) and your workers’ compensation insurer if any information in
Sections 2, 3 or 4 changes and you still want to exclude relatives from workers’ compensation coverage.
File a copy of this form with the Department of Labor and Industry.
In person
By mail
By fax
Department of Labor and Industry
Department of Labor and Industry
(651) 215-9099
Special Compensation Fund
Special Compensation Fund
443 Lafayette Road N.
P.O. Box 64229
St. Paul, MN 55155
St. Paul, MN 55164-0229
Notice
The election to exclude relatives from workers' compensation coverage is not effective unless this form
has been filed with DLI. If the information provided on this form is accurate and meets the statutory requirements,
the effective date of this exclusion will be based on the date DLI receives this form.
DLI does not guarantee that this election to exclude the relatives listed in Section 4 from workers' compensation
coverage is legally effective. The manager signing this form is responsible for determining the LLC’s legal obligations
and for correctly and accurately completing this form. DLI will notify you of potential defects if they are apparent, but
you are encouraged to consult an attorney about the legal effect of this election. If the information provided is not
accurate and complete, or the information changes, the LLC or manager(s) may be liable for workers’ compensation
injuries of the relatives listed in Section 4.
The information you provide on this form may be available to the public upon request.
This document can be given to you in Braille, large print or audio by calling (651) 284-5019 or 1-800-342-5354.
Questions? Contact Dave Horning at (651) 284-5422 or dave.horning@state.mn.us.
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