Form C 105 51 PDF Details

In the bustling world of business operations, navigating the complexities of legal requirements stands as a critical endeavor for corporations, particularly when it pertains to workers' compensation. Among the myriad forms and notifications that businesses must manage, the C-105.51 form holds particular significance for corporations within New York State. This form serves as a Notice of Election, designed for corporations that are mandated by the New York State Workers' Compensation Law to provide coverage for their employees, yet wish to exclude certain individuals from this requirement—specifically, the sole shareholder-officer or two executive officers/shareholders, assuming they own all of the corporation's stock. Detailed within the form are provisions for both one-person and two-person corporations, outlining the process by which these entities can officially make such an election. This declaration entails a certification process, where the concerned officer(s) affirm their stock ownership, their exclusive operation of the corporation, and their decision to waive workers' compensation coverage for themselves, under specified conditions. The form’s stipulations extend to outlining the conditions under which these elections are deemed final and binding, alongside how revocations can be processed. Such details underscore the importance of understanding the legal nuances embedded within the C-105.51 form, ensuring corporations comply with the law while aligning with their operational needs.

QuestionAnswer
Form NameForm C 105 51
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names10551 form, nys exclude workers, c 105 51 form, exclude workers

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NameTitleName

State of New York

WORKERS' COMPENSATION BOARD

NOTICE OF ELECTION OF A CORPORATION WHICH IS REQUIRED TO HAVE COVERAGE FOR ITS EMPLOYEES UNDER THE NEW YORK STATE WORKERS' COMPENSATION LAW TO EXCLUDE THE SOLE SHAREHOLDER-OFFICER OR ONE OF THE TWO OR BOTH EXECUTIVE OFFICERS-SHAREHOLDERS OF THE CORPORATION FROM SUCH COVERAGE

To: (Print name and address of insurance carrier here.)

TAKE NOTICE that under the provisions of Section 54, subdivision 6, of the Workers' Compensation Law as amended, the corporation named below elects to exclude the executive officer(s) named below from coverage under the New York State Workers' Compensation Law with respect to all the policies issued to the corporation by the insurance carrier named above.

Name of Corporation _____________________________________________________________________________________

Address of Corporation ___________________________________________________________________________________

Incorporated Under the Laws of the State of __________________________________________________________________

Type: One-person corp. Two-person corp. (A two-person corporation may elect to exclude one or both executive officers, provided that between them they own all the stock in the corporation, and that each officer owns at least one share of stock.)

ExecutiveOfficer(s)

1.

Name _________________________________ Title ___________________________________

to be Excluded from

 

 

Policy

2.

Name__________________________________ Title ___________________________________

CERTIFICATION

USE FOR ONE-PERSON CORPORATION

I, ___________________________________, certify that I am the sole executive officer of the above-named corporation; that I

Name

have been since _______________the sole owner of all issued and outstanding stock of the corporation and hold all the offices

Date

pursuant to paragraph (e) of Section 715 of the Business Corporation Law. (Affix corporate seal below, if you have one.)

____________________________________________ ___________________________ _____________________________

Signature of OfficerDateTelephone No.

USE FOR TWO-PERSON CORPORATION

We, _____________________________ , ________________________________ and _______________________________,

_____________________________ certify that we are the two executive officers of the above-named corporation, having been

Title

duly appointed by corporate resolution; that we have been since ______________ the sole owners of all issued and outstanding

Date

stock and that each of us owns at least one share of stock of the corporation, and that we hold all of the offices pursuant to paragraph (e) of Section 715 of the Business Corporation Law. (Affix corporate seal below, if you have one.)

_____________________________________________ __________________________ ______________________________

Signature of Officer

Date

Telephone No.

_______________________________________________________

__________________________________

_______________________________________

Signature of Officer

Date

Telephone No.

THIS ELECTION IS FINAL AND BINDING

UPON THE OFFICER(S) NAMED UNTIL

REVOKED BY THE CORPORATION.

See reverse side for relevant portions of Sec. 54, subd. 6 (WCL)

and Sec. 715, Par. (e) of the Business Corporation Law.

C-105.51 (1-04)

CORPORATE

SEAL*

*If the corporation does not have a seal, check here q

www.wcb.ny.gov

Section 54, Subdivision 6 of the

New York State Workers' Compensation Law

b. An executive officer of any corporation who at all times during the period involved owns all of the issued and outstanding stock of the corporation and holds all of the offices pursuant to paragraph (e) of section 715 of the business corporation law and who is the executive officer of a corporation having other persons who are employees required to be covered under this chapter shall be deemed to be included in the compensation insurance contract or covered under a certificate of self-insurance unless the officer elects to be excluded from the coverage of this chapter. Such election shall be made by the corporation filing a notice that the corporation elects to exclude the executive officer of such corporation named in the notice from coverage of this chapter. Such election shall be filed with the insurance carrier or the chair in the case of self-insurance upon a form prescribed by the chair of the workers' compensation board. Such election shall be effective with respect to all policies issued to such corporation by such insurance carrier as long as it shall continuously insure the corporation and shall be final and binding upon the executive officer named in the notice until revoked by the corporation in accordance with paragraph a of this subdivision.

d. Any two executive officers of a corporation who at all times during the period involved between them own all of the issued and outstanding stock of the corporation and hold all such offices, provided, however that each officer must own at least one share of stock, who are the executive officers of such corporation having other persons who are employees required to be covered under this chapter shall be deemed to be included in the compensation insurance contract or covered under a certificate of self-insurance unless one or both the officers elect to be excluded from the coverage of this chapter. Such election shall be made by any such corporation filing a form prescribed by the chair of the workers' compensation board with the insurance carrier or the chair in the case of self-insurance giving notice that the corporation elects to exclude one or both of the executive officers of such corporation named in the notice from the coverage of this chapter. Such election shall be effective with respect to all policies issued to such corporation by such insurance carrier as long as it shall continuously insure the corporation and shall be final and binding upon the executive officers as named in the notice until revoked by the corporation. If such election is revoked, it shall be in writing on a form prescribed by the chair and shall be filed with the chair and the insurance carrier. Such revocation shall not be effective until thirty days after such filing.

Section 715, Paragraph (e) of the

Business Corporation Law

Any two or more offices may be held by the same person, except the offices of president and secretary. When all of the issued and outstanding stock of the corporation is owned by one person, such person may hold all or any combination of offices.

C-105.51 (1-04) Reverse

How to Edit Form C 105 51 Online for Free

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c 105 51 form writing process detailed (step 1)

2. Once the last part is complete, you need to include the required particulars in pursuant to paragraph e of Section, Signature of Officer Date, USE FOR TWOPERSON CORPORATION We, Name, Title, Name, certify that we are the two, Title, duly appointed by corporate, Date, stock and that each of us owns at, paragraph e of Section of the, Signature of Officer Date, THIS ELECTION IS FINAL AND BINDING, and REVOKED BY THE CORPORATION so you can go to the next stage.

Stage number 2 in submitting c 105 51 form

Many people frequently get some points wrong while filling out stock and that each of us owns at in this area. Don't forget to revise everything you enter here.

3. In this part, look at wwwwcbnygov, See reverse side for relevant, and Sec Par e of the Business, and If the corporation does not have a. Each one of these should be completed with highest precision.

If the corporation does not have a, See reverse side for relevant, and wwwwcbnygov of c 105 51 form

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