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WCCW

Workers' Compensation Coverage Waivers System

Eligibility

Renew Waiver

Business

Mailing Address

Business Locations

Name Street City Zip

Ownership Information

Name Title % of Ownership

Nature of Business

Confirmation and Acknowledgement

By signing below, you certify under penalty of perjury that you are an owner, partner, member, manager, or corporate officer of the business named above and are authorized to make statements concerning what is currently listed on the operating agreement/by-laws. You also certify that your company does not have any employees that are not owners, partners, or corporate officers. You acknowledge that all individuals listed above waive any right that they might have to the benefits provided by the Utah Workers' Compensation Act and the Utah Occupational Disease Act. You further certify the information is accurate and verifiable.