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Workers' Compensation Exemption Registry
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Register an Initial Exemption
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Data Entry
Initial Workers Compensation Exemption
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Qualification
Physical Address
Mail Address
License
Confirmation
Signature
Print Form
To qualify a Workers' Compensation Exemption Registration, the business entity must be identified and applicant details provided.
Qualification:
Qualification Type:
[Select One]
Family has at least 95% ownership
Member of a LLC and owns at least 20%
Officer of a Corporation
Partner of a LP or LLP or GP and owns at least 20%
Religious Sect Business Entity
Religious Sect Sole Proprietor
Sole Proprietor
*
FEIN:
*
xx-xxxxxxx
What's this?
Entity Control #:
*
What's this?
The name will be shown after a Secretary of State Control # is entered.
Business Entity Name:
*
Applicant:
First Name:
*
Middle Name:
Last Name:
*
Birth Date:
*
mm/dd/yyyy
Last 4 SSN:
*
Phone:
*
(xxx) xxx-xxxx
Confirm Phone:
*
(xxx) xxx-xxxx
Email:
Confirm Email:
*