Form C-105.51 Notice of Election of a Corporation Which Is Required to Have Coverage for Its Employees - New York

Form c-105.51 or the "Notice Of Election Of A Corporation Which Is Required To Have Coverage For Its Employees" is a form issued by the New York State Department of Labor.

Download a fillable PDF version of the Form c-105.51 down below or find it on the New York State Department of Labor Forms website.

ADVERTISEMENT
State of New York
WORKERS' COMPENSATION BOARD
NOTICE OF ELECTION OF A CORPORATION WHICH IS REQUIRED TO HAVE COVERAGE FOR ITS
EMPLOYEES UNDER THE NEW YORK STATE WORKERS' COMPENSATION LAW TO EXCLUDE THE
SOLE SHAREHOLDER-OFFICER OR ONE OF THE TWO OR BOTH EXECUTIVE
OFFICERS-SHAREHOLDERS OF THE CORPORATION FROM SUCH COVERAGE
To: (Print name and address of insurance carrier here.)
(Print name and address of insurance carrier here)
TAKE NOTICE that under the provisions of Section 54, subdivision 6, of the Workers' Compensation Law as amended, the
corporation named below elects to exclude the executive officer(s) named below from coverage under the New York State
Workers' Compensation Law with respect to all the policies issued to the corporation by the insurance carrier named above.
Name of Corporation _____________________________________________________________________________________
Address of Corporation ___________________________________________________________________________________
Incorporated Under the Laws of the State of __________________________________________________________________
Type:
One-person corp.
Two-person corp.
(A two-person corporation may elect to exclude one or both executive
officers, provided that between them they own all the stock in the corporation, and that each officer owns at least one share of
stock.)
ExecutiveOfficer(s)
1. Name _________________________________ Title ___________________________________
to be Excluded from
Policy
2. Name__________________________________ Title ___________________________________
CERTIFICATION
USE FOR ONE-PERSON CORPORATION
I, ___________________________________, certify that I am the sole executive officer of the above-named corporation; that I
Name
have been since _______________the sole owner of all issued and outstanding stock of the corporation and hold all the offices
Date
pursuant to paragraph (e) of Section 715 of the Business Corporation Law. (Affix corporate seal below, if you have one.)
____________________________________________ ___________________________ _____________________________
Signature of Officer
Date
Telephone No.
USE FOR TWO-PERSON CORPORATION
We, _____________________________ , ________________________________ and _______________________________,
Name
Title
Name
_____________________________ certify that we are the two executive officers of the above-named corporation, having been
Title
duly appointed by corporate resolution; that we have been since ______________ the sole owners of all issued and outstanding
Date
stock and that each of us owns at least one share of stock of the corporation, and that we hold all of the offices pursuant to
paragraph (e) of Section 715 of the Business Corporation Law. (Affix corporate seal below, if you have one.)
_____________________________________________ __________________________ ______________________________
Signature of Officer
Date
Telephone No.
_______________________________________________________ __________________________________ _______________________________________
Signature of Officer
Date
Telephone No.
THIS ELECTION IS FINAL AND BINDING
CORPORATE
UPON THE OFFICER(S) NAMED UNTIL
SEAL*
REVOKED BY THE CORPORATION.
*If the corporation does not
See reverse side for relevant portions of Sec. 54, subd. 6 (WCL)
q
have a seal, check here
and Sec. 715, Par. (e) of the Business Corporation Law.
C-105.51 (1-04)
www.wcb.state.ny.us
State of New York
WORKERS' COMPENSATION BOARD
NOTICE OF ELECTION OF A CORPORATION WHICH IS REQUIRED TO HAVE COVERAGE FOR ITS
EMPLOYEES UNDER THE NEW YORK STATE WORKERS' COMPENSATION LAW TO EXCLUDE THE
SOLE SHAREHOLDER-OFFICER OR ONE OF THE TWO OR BOTH EXECUTIVE
OFFICERS-SHAREHOLDERS OF THE CORPORATION FROM SUCH COVERAGE
To: (Print name and address of insurance carrier here.)
(Print name and address of insurance carrier here)
TAKE NOTICE that under the provisions of Section 54, subdivision 6, of the Workers' Compensation Law as amended, the
corporation named below elects to exclude the executive officer(s) named below from coverage under the New York State
Workers' Compensation Law with respect to all the policies issued to the corporation by the insurance carrier named above.
Name of Corporation _____________________________________________________________________________________
Address of Corporation ___________________________________________________________________________________
Incorporated Under the Laws of the State of __________________________________________________________________
Type:
One-person corp.
Two-person corp.
(A two-person corporation may elect to exclude one or both executive
officers, provided that between them they own all the stock in the corporation, and that each officer owns at least one share of
stock.)
ExecutiveOfficer(s)
1. Name _________________________________ Title ___________________________________
to be Excluded from
Policy
2. Name__________________________________ Title ___________________________________
CERTIFICATION
USE FOR ONE-PERSON CORPORATION
I, ___________________________________, certify that I am the sole executive officer of the above-named corporation; that I
Name
have been since _______________the sole owner of all issued and outstanding stock of the corporation and hold all the offices
Date
pursuant to paragraph (e) of Section 715 of the Business Corporation Law. (Affix corporate seal below, if you have one.)
____________________________________________ ___________________________ _____________________________
Signature of Officer
Date
Telephone No.
USE FOR TWO-PERSON CORPORATION
We, _____________________________ , ________________________________ and _______________________________,
Name
Title
Name
_____________________________ certify that we are the two executive officers of the above-named corporation, having been
Title
duly appointed by corporate resolution; that we have been since ______________ the sole owners of all issued and outstanding
Date
stock and that each of us owns at least one share of stock of the corporation, and that we hold all of the offices pursuant to
paragraph (e) of Section 715 of the Business Corporation Law. (Affix corporate seal below, if you have one.)
_____________________________________________ __________________________ ______________________________
Signature of Officer
Date
Telephone No.
_______________________________________________________ __________________________________ _______________________________________
Signature of Officer
Date
Telephone No.
THIS ELECTION IS FINAL AND BINDING
CORPORATE
UPON THE OFFICER(S) NAMED UNTIL
SEAL*
REVOKED BY THE CORPORATION.
*If the corporation does not
See reverse side for relevant portions of Sec. 54, subd. 6 (WCL)
q
have a seal, check here
and Sec. 715, Par. (e) of the Business Corporation Law.
C-105.51 (1-04)
www.wcb.state.ny.us
Section 54, Subdivision 6 of the
New York State Workers' Compensation Law
b. An executive officer of any corporation who at all times during the period involved owns all of the
issued and outstanding stock of the corporation and holds all of the offices pursuant to paragraph (e)
of section 715 of the business corporation law and who is the executive officer of a corporation
having other persons who are employees required to be covered under this chapter shall be deemed
to be included in the compensation insurance contract or covered under a certificate of
self-insurance unless the officer elects to be excluded from the coverage of this chapter. Such
election shall be made by the corporation filing a notice that the corporation elects to exclude the
executive officer of such corporation named in the notice from coverage of this chapter. Such
election shall be filed with the insurance carrier or the chair in the case of self-insurance upon a form
prescribed by the chair of the workers' compensation board. Such election shall be effective with
respect to all policies issued to such corporation by such insurance carrier as long as it shall
continuously insure the corporation and shall be final and binding upon the executive officer named in
the notice until revoked by the corporation in accordance with paragraph a of this subdivision.
d. Any two executive officers of a corporation who at all times during the period involved between
them own all of the issued and outstanding stock of the corporation and hold all such offices,
provided, however that each officer must own at least one share of stock, who are the executive
officers of such corporation having other persons who are employees required to be covered under
this chapter shall be deemed to be included in the compensation insurance contract or covered under
a certificate of self-insurance unless one or both the officers elect to be excluded from the coverage
of this chapter. Such election shall be made by any such corporation filing a form prescribed by the
chair of the workers' compensation board with the insurance carrier or the chair in the case of
self-insurance giving notice that the corporation elects to exclude one or both of the executive
officers of such corporation named in the notice from the coverage of this chapter. Such election
shall be effective with respect to all policies issued to such corporation by such insurance carrier as
long as it shall continuously insure the corporation and shall be final and binding upon the executive
officers as named in the notice until revoked by the corporation. If such election is revoked, it shall
be in writing on a form prescribed by the chair and shall be filed with the chair and the insurance
carrier. Such revocation shall not be effective until thirty days after such filing.
Section 715, Paragraph (e) of the
Business Corporation Law
Any two or more offices may be held by the same person, except the offices of president and
secretary. When all of the issued and outstanding stock of the corporation is owned by one person,
such person may hold all or any combination of offices.
C-105.51 (1-04) Reverse

Download Form C-105.51 Notice of Election of a Corporation Which Is Required to Have Coverage for Its Employees - New York

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