Get Specific Person Exclusion Form - Caom.com

Filling out the Specific Person Exclusion Form is an important step for individuals or entities wishing to exclude certain individuals from Workers' Compensation coverage. This guide provides clear, step-by-step instructions to ensure that users, regardless of their legal experience, can complete the form accurately and effectively.

Follow the steps to accurately complete the form.

1. Click the ‘Get Form’ button to access the form in the online editor.
2. Enter the name of the entity in the designated field.
3. Provide the Federal Employer Identification Number (FEIN) in the appropriate box.
4. Select the legal form of the entity by checking the correct option: Sole Proprietor, Partnership, Corporation, or Limited Liability Company.
5. Indicate the persons eligible for exclusion based on the legal entity type by filling in the specific areas as applicable. Include details such as relationship, stock ownership percentage, and signatures.
6. If applicable, complete the Corporate Board Resolution section, ensuring that it aligns with the Articles of Incorporation and is properly certified.
7. If relevant, fill out the Limited Liability Company Consent section confirming that the decision is supported by a majority vote.
8. Review all entries for accuracy and completeness, ensuring that the form is fully filled out as it is not valid otherwise.
9. Save any changes made to the form. You may then choose to download, print, or share the form as needed.

Start filling out your Specific Person Exclusion Form online today!