Revocation coverage printable 2026

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The document outlines the process for a corporation in New York to revoke its election to exclude executive officers from workers' compensation coverage. It details the necessary steps, including filing a notice with the Workers' Compensation Board and the insurance carrier, and specifies that the revocation becomes effective 30 days after filing. The document also references relevant sections of the New York Workers' Compensation Law regarding coverage for executive officers.

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Click ‘Get Form’ to open the revocation coverage printable in the editor.
Begin by entering the name and address of your insurance carrier in the designated fields. This information is crucial for proper processing.
Fill in the name of your corporation and its address. Ensure that this matches your official documents for accuracy.
Select whether your corporation is a one-person or two-person corporation by checking the appropriate box.
List the names and addresses of executive officers included in the policy. Provide their titles as well, ensuring all details are correct.
In the certification section, enter your name and title, confirming that the revocation was duly made at a board meeting.
Finally, add your signature, telephone number, title, and date before submitting. If applicable, affix your corporate seal or check the box if you do not have one.

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c105 55 form fillable

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