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%MPLOYERS' America's small business insurance spec/allsO CA Waiver of Workers' Compensation Coverage Named Insured: Policy No./Quote No. I EIG 2514073-00 Pursuant to California Labor Code section 3352(p), I hereby certify, under penalty of perjury, that I am an officer or member of the board of directors of the above-named insured, which is a quasi -public or private corporation, and that I own at least 15 percent (15%) of the issued and outstanding stock of the above-named insured corporation. As a qualifying officer or member of the board of directors, I elect to be excluded from the corporation's workers' compensation insurance policy with the above - referenced insurer. I understand and agree that this written waiver will be effective upon the date of receipt and acceptance by the corporation's insurer and it shall remain in effect until I provide the insurer with a written withdrawal of this waiver. I understand and agree that by signing this waiver, I will not be entitled to coverage under the insured's workers' compensation policy with the above -referenced insurer if an employment-related injury occurs. PRINT OFFICER'S/ MEMBER OF BOARD OF DIRECTOR'S FULL NAME OFFICER'S/MEMBER OF BOARD OF DIRECTOR'S DATE SIGNATURE ACCEPTED: [Insurance Company] DATE NOTE TO EMPLOYER: The exclusion will be endorsed to the policy upon our receipt and acceptance of a signed and properly completed form. The person electing exclusion must sign this form. Company representatives may not sign on behalf of the individual. One exclusion per form. If policy contains multiple Named Insureds, an individual will need to submit a waiver for each Named Insured for which they are eligible. Submit additional forms if needed. Submit completed forms to: E-mail: westunderwriting@employers.com Mail: EMPLOYERS, PO Box 539003, Henderson, NV 89053-9003 AB 2883 compliant In California, workers' compensation insurance and services may be offered through Employers Compensation Insurance Company, Employers / 1% Preferred Insurance Company and Employers Assurance Company. EIG Services, Inc. (in California, ads EIG Insurance Services) is an affiliated IV agency and adjuster, Not all insurers do business in all jurisdictions. UW_PH_0024_CA Rev. 1012016 ✓) 5l