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Request Number is 123456
Please download the Exclusion Signature form by clicking the "Download Signature Document" button below.
After you download the Exclusion signature form, print the form, and then email, fax, or deliver in person to the owners or members for signature. Once the document is signed, you should review it to ensure the document is signed correctly. Any incomplete or improperly signed document may delay the processing of the Request. Upon receipt of all necessary signatures, please upload the form using "Complete and attach signed Certificate of Compliance" option to finish the submission. Do not select this option until you have all signatures.
Certificate of Compliance(COC)
  • Type Of Request
  • Attach Signed COC
    • Requester Information
    • Business Information
    • Mailing Address Information
    • Insurance Information
    • Business Owner Information
    • Exclusion Form Information
Type Of Request
Select the type of request to proceed further.
Select whether this is a new Certificate of Compliance or you are completing the previously submitted Certificate of Compliance.
The Certificate of Compliance requires signature on the form.
Start new Certificate of Compliance Complete and attach signed Certificate of Compliance
Attach Signed Certificate of Compliance
Attach the signed ceritificate of compliance form.
COC Request Number
*Required
Upload Signed COC Document
*Required
Requester Information
Provide the requester information.
Please review the instructions completely prior to completing this application. View COC Instructions.
Name
*Required
Email
*Required
Title or Company Position
*Required
Business Information
Provide the business information.
What is your business type?
*Required
Are you organized as Corporation or LLC?
Yes No
*Required
Business Name
*Required
Federal Employer Identification Number or SSN
*Required
Business Address (P.O. Box is not acceptable)
*Required
City
*Required
State
*Required
Postal Code
*Required
Phone
*Required
SDAT Department ID
Mailing Address Information
Provide the mailing address.
Mailing Address
*Required
City
*Required
State
*Required
Postal Code
*Required
Insurance Information
Provide the insurance information.
Insurance company name
NCCI number
Insurance company notified date
Business Owner Information
Provide the business owner information.

Type of Corporation

  • is an officer of a close corporation, as defined in 4-101(b) of the Corporations and Associations Article; or
  • is an officer of a close corporation, as defined under the laws of the jurisdiction in which the corporation is incorporated.

  • No more than five officers of a corporation described in subsection (b)(2) of this section may elect to be exempt under subsection (b)(2) of this subsection.

  • Is an officer of a corporation that earns at least 75% of its income from farm operations; and
  • Owns at least 20% of the outstanding capital stock of the corporation;

  • is an officer of a professional corporation, as defined in 5-101(c) or (f) of the Corporations and Associations Article;
  • owns at least 20% of the outstanding capital stock of the corporation; and
  • performs for the corporation a professional service, as defined in 5-101(g) of the Corporations and Associations Article;

  • is a member of a limited liability company, as defined in 4A-101(j) or (l) of the Corporations and Associations Article; and
  • owns at least 20% of the outstanding interests in profits of the limited liability company.

Exclusion Form
Provide the exclusion information.

Pursuant to Labor & Employment Article §9-206, Annotated Code of Maryland, officers or members of certain business entities may elect to be exempt from workers' compensation insurance coverage by filing this Exclusion Form with the Commission.

BUSINESS DETAILS
Business Name
VivSoft
FEIN or SSN
123456789
SDAT Department Id
Business Address
City
State
Postal Code
Phone
Mailing Address
City
State
Postal Code
Type of Corporation
OWNERSHIP DETAILS FOR EXCLUSION
EXCLUSION FORM SIGNATURE DETAILS

Before you begin: You must first save and generate the Exclusion Signature form by clicking the "Save & Generate Document" button below.
After you generate the Exclusion signature form, print the form, and then email, fax, or deliver in person to the owners or members for signature. Once the document is signed, you should review it to ensure the document is signed correctly. Any incomplete or improperly signed document may delay the processing of the Request. Upon receipt of all necessary signatures, please upload the form below. Do not select this option until you have all signatures.
Please make sure you upload Signed document in .pdf format using the request number.
NOTE: By signing this Exclusion Form, each officer or member affirms under the penalties of perjury that the information contained in this form is true and correct as to that officer or member, to the best of the officer's or member's knowledge, information, and belief.

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