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Xico Workers NAME Compensation Act, 52-1-1, et seq. or the New Mexico Occupational Disease Disablement Law, 52-3-1, et seq. (the Acts). I am employed by , a Corporation NAME OF CORPORATION subject to the provisions of one or both of the Acts. Pursuant to 52-1-7 or 52-3-6 of the Acts, I AFFIRMATIVELY ELECT NOT TO ACCEPT THE PROVISIONS OF THE WORKERS COMPENSATION ACT OR THE NEW MEXICO OCCUPATIONAL DISEASE DISABLEMENT LAW. I meet the qualifications of 52-.

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