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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 Exclusion form" option to finish the submission. Do not select this option until you have all signatures.
Exclusion
  • Type Of Request
  • Attach Signed Exclusion
    • Requester Information
    • Business Information
    • Insurance Information
    • Business Owner Information
    • Exclusion Signature Information
Type Of Request
Select the type of request to proceed further.
Select whether this is a new Exclusion or you are completing the previously submitted Exclusion.
The Exclusion requires signature on the form.
Start new Exclusion form Complete and attach signed Exclusion form
Attach Signed Exclusion
Attach the signed exclusion form.
Exclusion Request Number
*Required
Upload Signed Exclusion Document
*Required
Requester Information
Provide the requester 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.

Name
*Required
Email
*Required
Title or Company Position
*Required
Business Information
Provide the business information.
Business Name
*Required
Federal Employer Identification Number
*Required
Business Address
*Required
City
*Required
State
*Required
Postal Code
*Required
Phone
*Required
SDAT Department ID
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 Signature Information
Provide the electronic signature information.

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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