Form Dwc 11 C PDF Details

The Department of Workforce Development (DWD) has released a new form, Form Dwc 11 C, to be used by employees and employers in the state of Wisconsin. The form is designed to help employees and employers better understand the workers' compensation system in Wisconsin. It can also be used as a reference guide for specific information about worker's compensation benefits. The form can be downloaded from the DWD website or requested through the mail.

QuestionAnswer
Form NameForm Dwc 11 C
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesDBA, Insurer, DWC-11-C, TDD

Form Preview Example

State of Rhode I sland, Department of Labor and Training, Workers’ Compensation Unit

P.O. Box 20190, Cranston, RI 02920-0942

Phone (401) 462-8100 TDD ( 401) 462-8006

ELECTI ON BY EXEMPT CORPORATE OFFI CER TO BECOME SUBJECT TO W ORKERS’ COMPENSATI ON

( TI TLE 2 8 CHAPTERS 2 9 t hrough 3 8 )

** * * THI S FORM ONLY APPLI ES TO ANY PERSON W HO W AS APPOI NTED A CORPORATE OFFI CER

AND W AS NOT PREVI OUSLY AN EMPLOYEE OF THE CORPORATI ON

BETW EEN 1 / 1 / 1 9 9 9 AND 1 2 / 3 1 / 2 0 0 1 * * * *

I,

 

 

Name

 

Soc. Sec. No.

Address

 

Date of Birth

 

 

Corporate Title

an officer of the following business,

 

 

 

Name

 

DBA

 

Address

 

FEIN

 

 

 

I nsurer

 

 

 

I nsurance Policy #

 

do hereby give notice in writing that I elect to become subject to the provisions of the Rhode I sland Workers’ Compensation Statute (Title 28 Chapters 29 through 38) .

Under penalties of perjury I declare that I have examined this form and to the best of my knowledge it is true, correct and complete. I further acknowledge that false statements on the within document may subject me to criminal prosecution.

Signat ure _________________________________ Not ary Public Signat ure __________________________

Dat e _____________________________________ Dat e Commission Expires _________________________

A filing fee of five dollars ($5.00) is required with the submission of this form. Please enclose a check or money order payable to Rhode I sland Department of Labor and Training. The employer should retain a copy of this form, send a copy to the insurance company and send an original to the Department of Labor and Training. For a dated, receipt copy, include a copy with the original sent to the Department of Labor and Training with a SELF-ADDRESSED, STAMPED ENVELOPE. The original and copy will be date stamped. The original will be retained for our files. The stamped copy will be returned in the envelope provided.

D W C-11-C ( 1/ 2002)

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