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Get North Carolina Officer Exclusion Form
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How to fill out the North Carolina Officer Exclusion Form online
The North Carolina Officer Exclusion Form allows corporate officers to opt out of coverage under the North Carolina Workers' Compensation Act. This guide provides clear, step-by-step instructions to help you complete the form online with confidence.
Follow the steps to successfully complete the online form.
- Press the ‘Get Form’ button to access the North Carolina Officer Exclusion Form and open it for editing.
- Enter the corporate name in the designated field accurately to ensure proper identification.
- Fill in the policy number associated with your corporation's workers' compensation insurance. This should match the number on your insurance documentation.
- Specify the effective date of the exclusion, indicating when you wish the exemption to take effect.
- For each corporate officer electing to be exempt, provide their full name, title, and signature in the respective fields. Ensure that all signatures are dated appropriately.
- Review all entered information for accuracy and completeness. It's essential to verify that names, titles, and dates are correct.
- Once you have confirmed that all information is accurate, save your changes. You can then download, print, or share the completed form as needed.
Complete your documents online today for a smooth and efficient process.
The First Report of Injury is one of the forms you must fill out for any work related Injury, Illness, or Near Miss. This form along with the Worker's Compensation Form 19 will be used for Worker's Compensation consideration. Return the completed and signed form to EHS Box 8007.
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