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?No
Fillable fields0
Avg. time to fill out15 sec
Other namesexclusion md, compensation exclusion, maryland exclusion form, maryland workers exempt

Form Preview Example

MARYLAND 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 original 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

410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us

Form IC-16 (01/11)

Watch Maryland Exclusion Form Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .