CA Workers Compensation Officer Waiver Form - AmTrust Financial 2025

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  1. Click ‘Get Form’ to open the CA Workers Compensation Officer Waiver Form in the editor.
  2. Begin by entering the 'Entity Name' at the top of the form. This should be the name of your professional corporation.
  3. In the certification section, confirm that you are an owner of a professional corporation and a practitioner rendering services for it. Ensure you check the box indicating you have health insurance coverage.
  4. Sign and print your full name in the designated fields. Include your title, signature, and date to validate your waiver.
  5. Review all entries for accuracy before submitting. Remember, only one individual may be excluded per form; additional forms are required for more exclusions.
  6. Once completed, submit the signed form to your broker as instructed in the notes section.

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The 27 form, also known as the Certificate of Insurance, provides proof of property insurance coverage to third parties, such as mortgagees or loss payees. It ensures that interested parties are aware of an active insurance policy covering a specific property.
130, Workers Compensation Application, is a self-contained Commercial Lines application that does not require the completion of the Applicant Information Section ( 125).
Form 130 is the standard application form for workers compensation insurance. This form is used when businesses apply for coverage or request changes to their existing policies. It gathers essential information about your business, such as: General details about your company (name, address, FEIN, etc.)
SPECIFIC WAIVER OF SUBROGATION These endorsements are common for construction projects, landlords, and management companies. The range of minimum premiums for specific waivers is $100-$250, and an average cost is 3% of the work comp premium derived from the payroll on a particular job.
Form 130: Workers Compensation Application This form is used when businesses apply for coverage or request changes to their existing policies. It gathers essential information about your business, such as: General details about your company (name, address, FEIN, etc.) Description of your operations and locations.

Facts about CA Workers Compensation Officer Waiver Form - AmTrust Financial

The CA Workers Compensation Officer Waiver Form allows owners of professional corporations in California to opt out of workers' compensation coverage while ensuring they have alternative health insurance.

Use cases of the form

Form filing requirements

How to submit the CA Workers Compensation Officer Waiver Form - AmTrust Financial?

Other important aspects to understand about completing CA Workers Compensation Officer Waiver Form - AmTrust Financial

Use cases of the form

This form is primarily required for owners of professional corporations who are actively engaged in providing professional services. For instance, a licensed attorney or a medical doctor who owns their practice can use this waiver to exclude themselves from workers' compensation coverage, provided they have adequate health insurance. This is particularly relevant for small business owners who may want to reduce their insurance costs while still maintaining personal health coverage.

Form filing requirements

To file the CA Workers Compensation Officer Waiver Form, it must be completed and signed by the individual owner. The form should be submitted promptly to ensure that the exclusion is effective immediately upon acceptance by the insurer. There are no specific deadlines for submission; however, it is advisable to submit it as soon as possible after establishing the corporation.

  • The form must be signed by the individual owner; company representatives cannot sign on behalf of the owner.
  • Only one individual can be excluded per form; additional forms are necessary for multiple exclusions.
  • The completed form must be submitted to your broker for processing.

How to submit the CA Workers Compensation Officer Waiver Form - AmTrust Financial?

To submit the CA Workers Compensation Officer Waiver Form, follow these steps: first, obtain a copy of the form from your broker or download it from an official source. Next, fill out all required fields accurately and ensure that you sign and date the document. After completing the form, send it directly to your insurance broker either via email or postal service, depending on their submission guidelines.

  1. Obtain a copy of the CA Workers Compensation Officer Waiver Form.
  2. Complete all sections of the form with accurate information.
  3. Sign and date the form where indicated.
  4. Submit the completed form to your insurance broker via email or mail.

Other important aspects to understand about completing CA Workers Compensation Officer Waiver Form - AmTrust Financial

It is crucial for individuals opting for this waiver to understand that by signing this document, they relinquish their right to workers' compensation benefits in case of work-related injuries. Additionally, this waiver remains effective until a written withdrawal is submitted to the insurer. Therefore, careful consideration should be given before deciding to opt-out.

  • The waiver only applies if you have an active health insurance policy or healthcare service plan.
  • This waiver does not affect any other employees covered under workers' compensation policies within the corporation.
  • 'Professional corporation' refers specifically to entities formed under California Corporations Code Section 13401.
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People also ask

A: No, you cannot waive workers compensation claim rights in California in most cases. It is generally illegal to ask employees to sign a waiver to not receive workers compensation benefits. The only exception to this is if a board member, executive owner, or executive officer wishes to waive their benefits.
While workers compensation is rather comprehensive, some individuals are exempt from workers comp in California. Under California Labor Code, Division 4, Part 1, Chapter 2, Section 3352, these workers include the following: Sole Proprietors and business owners (excluding roofers) Business owners.

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