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Request Number is 123456
Please download the Inclusion Signature form by clicking the "Download Signature Document" button below.
After you download the Inclusion 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 Inclusion" option to finish the submission. Do not select this option until you have all signatures.
Inclusion
  • Type Of Request
  • Attach Signed Inclusion
    • Requester Information
    • Business Information
    • Mailing Address Information
    • Insurance Information
    • Coverage and Signature Details
Type Of Request
Select the type of request to proceed further.
Select whether this is a new Inclusion or you are completing the previously submitted Inclusion.
The Inclusion requires signature on the form.
Start new Inclusion Complete and attach signed Inclusion
Attach Signed Inclusion Form
Attach the signed inclusion form.
Inclusion Request Number
*Required
Upload Signed Inclusion Document
*Required
Requester Information
Provide the requester information.
Pursuant to the Workers’ Compensation Act, Annotated Code of Maryland, Labor and Employment Article,§§ 9-219 and 9-227, sole proprietors and partners are excluded from coverage under the Act; however, such persons may elect to become covered employees under the Act.
To exercise this option, any sole proprietor or partner electing to be a covered employee must complete and sign this document.
Name
*Required
Email
*Required
Title or Company Position
*Required
Business Information
Provide the business information.
Business Name
*Required
Business Address
*Required
City
*Required
State
*Required
Postal Code
*Required
Phone
*Required
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
Insurance company notified date
Coverage Details
Provide the coverage information.

Before you begin: You must first save and generate the Inclusion Signature form by clicking the "Save & Generate Document" button below.
After you generate the Inclusion signature form, print the form, and then email, fax or deliver in person to the other parties for signature. Once the document is signed, you should review it to ensure all 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.

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