Application for Waiver Instructions.doc

Application for Waiver Instructions.doc - MAINE WORKERS...

Info icon This preview shows pages 1–2. Sign up to view the full content.

View Full Document Right Arrow Icon
MAINE WORKERS’ COMPENSATION BOARD I NSTRUCTIONS FOR C OMPLETING AN A PPLICATION FOR W AIVER OF W ORKERS C OMPENSATION I NSURANCE ALL APPLICANTS WAIVERS ARE NOT VALID UNTIL APPROVED BY THE BOARD . All applicants must sign and date the waiver application, and submit that form to the Board. You will receive a copy marked “Approved” with the effective date when/if your Waiver is accepted by the Board. Applicant-Employees : Fill in the full name and complete address of the person applying to waive coverage. Use a separate form for each applicant. Business-Employer : Fill in the complete name under which the company does business (DBA Name), complete address and phone number. Use a separate form for each business. Be sure to include the employer’s federal tax ID number. It is against the law to require an Owner, or the family member of an Owner, to WAIVE their right to workers’ compensation coverage as a pre-condition to employment. ANY PERSON MAY REVOKE OR RESCIND THAT PERSON’S WAIVER BY NOTIFYING THE WORKERS’ COMPENSATION BOARD, THEIR EMPLOYER, AND THE INSURANCE CARRIER, IN WRITING, 30 DAYS PRIOR TO THE DATE THEY WISH TO RESCIND THE WAIVER. DEFINITIONS OWNER - An individual that owns a share or all of the business (includes: S HAREHOLDERS , S TOCKHOLDERS , S OLE P ROPRIETORS , P ARTNERS , and M EMBERS OF A LLC). SPOUSE - A person with whom the Owner lives and to whom he/she is legally married. CHILD – The legal child of an Owner. PARENT – The legal mother or father of an Owner.
Image of page 1

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full Document Right Arrow Icon
Image of page 2
This is the end of the preview. Sign up to access the rest of the document.

{[ snackBarMessage ]}

What students are saying

  • Left Quote Icon

    As a current student on this bumpy collegiate pathway, I stumbled upon Course Hero, where I can find study resources for nearly all my courses, get online help from tutors 24/7, and even share my old projects, papers, and lecture notes with other students.

    Student Picture

    Kiran Temple University Fox School of Business ‘17, Course Hero Intern

  • Left Quote Icon

    I cannot even describe how much Course Hero helped me this summer. It’s truly become something I can always rely on and help me. In the end, I was not only able to survive summer classes, but I was able to thrive thanks to Course Hero.

    Student Picture

    Dana University of Pennsylvania ‘17, Course Hero Intern

  • Left Quote Icon

    The ability to access any university’s resources through Course Hero proved invaluable in my case. I was behind on Tulane coursework and actually used UCLA’s materials to help me move forward and get everything together on time.

    Student Picture

    Jill Tulane University ‘16, Course Hero Intern