FIT UNINCORPORATED ASSOCIATION TO EXCLUDE AN UNSALARIED EXECUTIVE OFFICER FROM COVERAGE PURSUANT TO SECTION 54, SUBDIVISION 6 OF THE WORKERS' COMPENSATION LAW To: (Print nameName and address of insuranceof carrier here) (Print and Address Insurance Carrier Here) TAKE NOTICE that under the provisions of Section 54, subdivision 6, of the New York Workers' Compensation Law as amended, the corporation or association named below hereby revokes, effective as provided by law, the election now in effe.
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How to fill out the NY C-105.53 online
Filling out the NY C-105.53 form is an essential procedure for not-for-profit corporations or unincorporated associations that wish to revoke the exclusion of an unsalaried executive officer from workers' compensation coverage. This guide will provide you with clear, step-by-step instructions to complete the process online with confidence.
Follow the steps to complete the NY C-105.53 form online
- Press the ‘Get Form’ button to access the NY C-105.53 form and allow it to open in the editor.
- Carefully fill in the name and address of the insurance carrier in the designated space.
- Under the section for the corporation or association, provide the official name of the entity submitting the revocation.
- Include the address of the corporation or association in the specified field.
- If applicable, indicate the state under which the corporation is incorporated.
- Enter the name of the unsalaried executive officer that is being included in the policy.
- Specify the title of the executive officer in the appropriate field.
- Sign the form to certify that the revocation was duly made during a meeting of the Board of Directors or authorized executive body.
- Fill in the date on which the revocation is being filed.
- Type your name and title under the signature section for verification.
- If applicable, affix the corporate seal in the designated area.
- Provide your telephone number for further communication.
- Once the form is completed, save your changes and choose to download, print, or share the completed form as needed.
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