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Get Cid Sole Proprietor Affirmative Election Form

STATE OF NEW MEXICO WORKERS COMPENSATION ADMINISTRATION CID SOLE PROPRIETOR AFFIRMATIVE ELECTION FORM I please print name under penalty of perjury and after having been duly sworn state that I affirmatively elect NOT TO ACCEPT the provisions of the Workers Compensation Act and the Occupational Disease and Disablement Law pursuant to NMSA 1978 52-1-7 or 52-3-6. In support of this election I affirm and acknowledge the following to be true 1 I am the sole owner of. Name of business please print clearly 2 I own all the assets of my business and am solely liable for the debts of my business. 3 No one works for me in my business. 4 I have a license from the Construction Industries Division and I am engaged in business activities that fall under the Construction Industries Licensing Act. 5 I understand that if I decide to hire any employee even if on a temporary basis I am required to buy workers compensation insurance immediately and to notify the Workers Compensation Administration* and that my business may be shut down if I fail to secure workers compensation insurance upon hiring an employee even temporarily. 7 I also understand that if I do hire an employee and fail to obtain workers compensation insurance I may be responsible for the costs associated with any claim for workers compensation benefits by such employee including the costs of medical and disability payments. 8 I further understand that by making this election not to accept the provisions of the Workers Compensation Act and Occupational Disease Disablement Law I will not be entitled to Signature UI Number Business Address FEIN Number City/State/Zip Phone Number STATE OF ss. COUNTY OF SUBSCRIBED AND SWORN OR AFFIRMED to before me on the day of Notary Public My commission expires Please retain a copy of this form for your records. In support of this election I affirm and acknowledge the following to be true 1 I am the sole owner of. Name of business please print clearly 2 I own all the assets of my business and am solely liable for the debts of my business. Name of business please print clearly 2 I own all the assets of my business and am solely liable for the debts of my business. 3 No one works for me in my business. 4 I have a license from the Construction Industries Division and I am engaged in business activities that fall under the Construction Industries Licensing Act. 3 No one works for me in my business. 4 I have a license from the Construction Industries Division and I am engaged in business activities that fall under the Construction Industries Licensing Act. 5 I understand that if I decide to hire any employee even if on a temporary basis I am required to buy workers compensation insurance immediately and to notify the Workers Compensation Administration* and that my business may be shut down if I fail to secure workers compensation insurance upon hiring an employee even temporarily. 5 I understand that if I decide to hire any employee even if on a temporary basis I am required to buy workers compensation insurance immediately and to notify the Workers Compensation Administration* and that my business may be shut down if I fail to secure workers compensation insurance upon hiring an employee even temporarily. 7 I also understand that if I do hire an employee and fail to obtain workers compensation insurance I may be responsible for the costs associated with any claim for workers compensation benefits by such employee including the costs of medical and disability payments.

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