WCCW

Eligibility

This is my first workers' compensation coverage waiver.

I currently have an active workers' compensation coverage waiver.

My workers' compensation coverage waiver is going to expire in 30 days or less.

My workers' compensation coverage waiver has already expired.

[Title]

[Content]

Renew Waiver

Business

Business Name

# of years in business

Mailing Address

Street

City

State

Zip

Phone

Fax

Re-enter email

Do you wish to recieve an email when it's time to renew the waiver? :

Business Locations

Is the business location the same as the mailing address?

Name	Street	City	Zip

Business Name

Street

City

Zip Code

Ownership Information

Does the company have any employees who are not owners, partners, or corporate officers?

Ownership Type

Federal Tax ID Number

Name	Title	% of Ownership

First Name

Middle Initial

Last Name

Title

Percent of Ownership

ID Type

ID Number

Principal Duties

E-Signature

Nature of Business

Industry Type

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.

Principal Name

Principal Title