Maryland Exclusion Form PDF Details

In the state of Maryland, officers or members of certain business entities have the unique opportunity to opt out of workers' compensation insurance coverage, a choice facilitated by the Maryland Exclusion Form as per Labor & Employment Article §9-206, Annotated Code of Maryland. This strategic decision allows individuals in leadership or ownership positions within specified company types—including close corporations, general corporations, farm corporations, professional corporations, and limited liability companies—to formally exclude themselves from the benefits and obligations of the state's workers' compensation system. To effectively make this election, the interested officer or member must complete and sign the Exclusion Form, submit it to the Workers' Compensation Commission as well as the insurance provider of the entity, and retain a copy for their records. This process requires the disclosing of essential information such as the company's name and address, the type of company, the insurance company's name, and the date the insurance company was notified. A notable aspect of completing this form is the requirement for the signing officer or member to affirm, under the penalty of perjury, the truthfulness and accuracy of the information provided to the best of their knowledge. Located at 10 East Baltimore Street in Baltimore, Maryland, the Workers' Compensation Commission oversees the administration of these exclusions, meticulously outlined on Form IC-16 (09/2019).

QuestionAnswer
Form NameMaryland Exclusion Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesform exclusion md, compensation exclusion, form workers md, form maryland compensation

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WORKERS’ COMPENSATION COMMISSION

EXCLUSION FORM

INSTRUCTIONS: Pursuant to Labor & Employment Article §9-206, Annotated Code of Maryland, officers or members of certain business entities may elect to be exempt from workers' compensation insurance coverage by filing this Exclusion Form with the Commission. To exercise this option, the officer or member making the election must sign this document, submit the form to the Workers’ Compensation Commission, a copy to the insurer of the company/corporation, and keep a copy for your files.

Company Name: ______________________________________________________________________

Address: ____________________________________________________________________________

City: _____________________

State: ___________

ZIP _______________________

Type of Company:

 

 

 

___ Close Corporation

___ General Corporation

___ Farm Corporation

___ Professional Corporation

___ Limited Liability Company

 

Insurance Company Name: _____________________________________________________________

Date Insurance Company Notified:_________________

Typed Name and Title of the Officer

% of

Personal

or Member Electing Exclusion

Ownership

Signature

____________________________________

________

___________________

____________________________________

________

___________________

____________________________________

________

___________________

____________________________________

________

___________________

____________________________________

________

___________________

NOTE: By signing this Exclusion Form, each officer or member affirms under the penalties of perjury that the information contained in this form is true and correct as to that officer or member, to the best of the officer’s or member’s knowledge, information, and belief.

10 East Baltimore Street Baltimore, Maryland 21202-1641

Form IC-16 (09/2019)

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