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Get AL WC14/15

Er of a corporation may elect annually to be exempt from coverage by filing written certification of the election with the department and the employer’s insurance carrier. ( ) I, __________________________________ choose to be excluded from my (PRINT FULL NAME) employer’s workers’ compensation insurance policy. I understand if a job related injury occurs I will not have insurance protection. _________________________________________________ _____ _________ SIGNED DATE TITLE At the end of a.

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