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Get MD WCC IC-02 2015-2023

Ess in and about the State of Maryland, and that on the date set forth below my signature, under the penalty of perjury, the following checked box represents my status as a covered employee. Check all that apply: I have elected to become a covered employee under § 9-227 of the Labor and Employment Article, Annotated Code of Maryland, and have submitted the requisite Inclusion form (IC15R) with the Workers’ Compensation Commission. I have not elected to become a covered employee under § 9-22.

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