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Get MD C-15R 2015-2024

Wcc.state. md. us INCLUSION FORM SOLE PROPRIETORS/ PARTNERS ELECTION FORM Pursuant to the provisions of 9-219 and 9-227 of the Labor and Employment Article Annotated Code of Maryland sole proprietors and partners are excluded from coverage under the Workers Compensation Act of Maryland. WORKERS COMPENSATION COMMISSION 10 East Baltimore Street Baltimore Maryland 21202-1641 Date Stamp WCC Use Only TEL 410 864-5100 or 1 800 492-0479 TTD MD Relay Service 1 800 735-2258 http //www. Such persons may elect to become covered employees under the Workers Compensation Act of Maryland. To exercise this option any sole proprietor or partner wishing to be a covered employee must complete and sign this document. IMPORTANT Submit original form to the Workers Compensation Commission a copy to the insurer and keep a copy for your files. Unless otherwise agreed upon this election will be effective upon the date of receipt by the Workers Compensation Commission* CURRENT DATE DATE INSURANCE COMPANY WAS NOTIFIED NAME OF INSURANCE COMPANY COMPANY NAME ADDRESS CITY STATE Name and Title of Person Electing Coverage Social Security Number FORM C-15R Rev* 07/2015 CLICK HERE TO CLEAR THE FORM ZIP Personal Signature. Such persons may elect to become covered employees under the Workers Compensation Act of Maryland. To exercise this option any sole proprietor or partner wishing to be a covered employee must complete and sign this document. IMPORTANT Submit original form to the Workers Compensation Commission a copy to the insurer and keep a copy for your files. IMPORTANT Submit original form to the Workers Compensation Commission a copy to the insurer and keep a copy for your files. Unless otherwise agreed upon this election will be effective upon the date of receipt by the Workers Compensation Commission* CURRENT DATE DATE INSURANCE COMPANY WAS NOTIFIED NAME OF INSURANCE COMPANY COMPANY NAME ADDRESS CITY STATE Name and Title of Person Electing Coverage Social Security Number FORM C-15R Rev* 07/2015 CLICK HERE TO CLEAR THE FORM ZIP Personal Signature. Such persons may elect to become covered employees under the Workers Compensation Act of Maryland. To exercise this option any sole proprietor or partner wishing to be a covered employee must complete and sign this document. IMPORTANT Submit original form to the Workers Compensation Commission a copy to the insurer and keep a copy for your files. Unless otherwise agreed upon this election will be effective upon the date of receipt by the Workers Compensation Commission* CURRENT DATE DATE INSURANCE COMPANY WAS NOTIFIED NAME OF INSURANCE COMPANY COMPANY NAME ADDRESS CITY STATE Name and Title of Person Electing Coverage Social Security Number FORM C-15R Rev* 07/2015 CLICK HERE TO CLEAR THE FORM ZIP Personal Signature. .

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