Maryland Exclusion Form PDF Details

The Maryland Exclusion Form is a legal document used to prohibit certain individuals from entering into or remaining in the State of Maryland. The form is typically used by employers, landlords, and other interested parties to prevent individuals with criminal histories or other harmful behaviors from entering their property or workplace. Anyone wishing to file an exclusion must have a legitimate reason for doing so, and the form must be completed in its entirety.

You will see details about the type of form you need to prepare in the table. It will tell you how much time you will need to fill out maryland exclusion form, exactly what fields you need to fill in and a few other specific details.

QuestionAnswer
Form NameMaryland Exclusion Form
Form Length1 pages
Fillable?Yes
Fillable fields23
Avg. time to fill out4 min 55 sec
Other namesform exclusion, maryland compensation form, form maryland compensation, compensation exclusion

Form Preview Example

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)

How to Edit Maryland Exclusion Form Online for Free

Number of tasks can be easier than preparing documentation with the help of the PDF editor. There is not much you have to do to enhance the form exclusion document - merely abide by these steps in the following order:

Step 1: Locate the button "Get Form Here" and select it.

Step 2: Now you're on the form editing page. You may enhance and add text to the document, highlight specified content, cross or check selected words, add images, insert a signature on it, erase unwanted fields, or take them out altogether.

Feel free to type in the next information to complete the form exclusion PDF:

writing maryland workers exempt part 1

In the of, Ownership and Personal, Signature area, note the information you have.

maryland workers exempt ofOwnership, and PersonalSignature fields to fill

Step 3: At the time you hit the Done button, the ready file is readily transferable to any type of of your devices. Or alternatively, you can deliver it by means of email.

Step 4: It will be easier to have duplicates of your document. There is no doubt that we will not reveal or view your information.

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