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EMPLINERIT <br />America's small business insurance specialist,- <br />CA <br />pecialist <br />CA Waiver of Workers' Compensation Coverage <br />Named Insured: <br />Policy No./Quote No. EIG 2514073-00 <br />��PL�:L•111�\i1:1�3.y_1�17SS�PuQ' �GC�3�C a t7 <br />Pursuant to California Labor Code section 3352(q), I hereby certify, under penalty of perjury, that I <br />am a general partner (if the insured is a partnership) or a managing member (if the insured is a <br />limited liability company) of the above-named insured. As a qualifying general partner or <br />managing member, I elect to be excluded from the insured's workers' compensation insurance policy <br />with the above -referenced insurer. I understand and agree that this written waiver will be effective <br />upon the date of receipt and acceptance by the partnership's or limited liability company's insurer and it <br />shall remain in effect until I provide the insurer with a written withdrawal of this waiver. I understand <br />and agree that by signing this waiver, I will not be entitled to coverage under the insured's <br />workers' compensation insurance policy with the above -referenced insurer if an employment-related <br />injury occurs. <br />PRINT GENERAL PARTNER'S/ <br />MANAGING MEMBER'S FULL NAME <br />GENERAL PARTNER/MANAGING MEMBER <br />SIGNATURE <br />ACCEPTED: <br />TITLE (GENERAL PARTNER or <br />MANAGING MEMBER) <br />DATE <br />[Insurance Company] DATE <br />NOTE TO EMPLOYER: The exclusion will be endorsed to the policy upon our receipt and <br />acceptance of a signed and properly completed form. The person electing exclusion must sign <br />this form. Company representatives may not sign on behalf of the individual. One exclusion <br />per form. If policy contains multiple Named Insureds, an individual will need to submit a waiver <br />for each Named Insured for which they are eligible. Submit additional forms if needed. <br />Submit complete forms to: <br />E-mail: westunderwriting@employers.com <br />Mail: EMPLOYERS, PO Box 539003, Henderson, NV 89053-9003 <br />In 2983 compliant ,r ¢,i' <br />InCalifornia,lin, workers' compensation insurance and services may y, offered vices, IncEmployers Compensation Insurance Company, Employers <br />Prefarretl Insurance Company and Employers Assurance Company. EIG Services, I, (in California, dba EIG Insurance Services) is an affiliated (1 <br />agency and adjuster. Not all insurers do business in all jurisdictions. Qe t �j <br />UW—PH 0025 CA Rev. 1012016 <br />