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TRusreo <br />Z�0 F"in, <br />YEARS <br />THE HARTFC%12G1 <br />Small Business Alliance Center <br />1 Griffin Road North <br />Windsor CT 06095 <br />Telephone (877) 287-1316 <br />Fax: (877) 538-1130 <br />EXCLUSION/INCLUSION COVERAGE SELECTION FORM <br />FOR AN OFFICER OF A CORPORATION; MEMBER OF AN LLC; <br />PARTNER OR SOLE PROPRIETOR <br />I, Adrian Visconti Barbour aka Avi Barbour, <br />Name of officer/member/partner/sole proprietor <br />President/Chief Executive of <br />Office Held <br />Ashrei Professional Services <br />Exact name of the Entity <br />Worker's Compensation Policy #: 76WEGGI7765 <br />Hereby elect to :(Place an "X" next to one ofthefollowing) <br />[ ] BE EXCLUDED FROM WORKER'S COMPENSATION COVERAGE <br />UNDER STATUTORY PROVISIONS. <br />[ X ] BE INCLUDED IN WORKER'S COMPENSATION COVERAGE <br />LL101=1: &WAVIL&I ll:161T/1,9[a]kEll <br />NOTE: THIS ELECTION WILL NOT BE EFFECTIVE UNTIL RECEIVED BY THE HARTFORD. <br />AFFIRMATION <br />Dated on this 5th day of January, 2015, <br />Signature of Employee <br />olgnzuv agn ^a Ev Aarlan v. HmMur <br />Adrian V. Barbour ��° a.rho. A,reo.r,-.a=.r e,.o_Q <br />eNT11=av5.010 142,5 n.0900rkes m [�5 <br />oaz.:zms.oi as 14 2,S �osoo <br />Employee Address: 1100 W Town & Country Road, Suite 1250, Orange, CA 92868 <br />This form is for information and verification purposes only. Please refer to your worker's <br />compensation policy for contract coverages and endorsements. <br />Itr <br />**PLEASE MAKE A COPY OF THIS FORM FOR EACH OFFICER OF A <br />d�Cf <br />CORPORATION; MEMBER OF AN LLC; PARTNER OR SOLE PROPRIETOR <br />THAT WISHES TO BE INCLUDED OR EXCLUDED FROM WORKERS' <br />\�N <br />COMPENSATION COVERAGE** <br />lyT n�1 <br />Exhibit C <br />