The employer must file this form in order that the corporate officer or limited liability company member be exempt from coverage, or to revoke their previously filed exemption. Rejection becomes effective the date of filing with the insurer. Where the employer has workers’ compensation insurance coverage, the employer must send this form to their workers’ compensation insurer. If no workers’ compensation coverage is in place, file this form with the Board.
The farm labor employer must file this form in order to request coverage for farm laborers, or to revoke their previously filed request.