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Get C105 32 Form 2004-2024

PORATION WHICH IS REQUIRED TO HAVE COVERAGE FOR ITS EMPLOYEES UNDER THE NEW YORK STATE WORKERS' COMPENSATION LAW TO EXCLUDE THE SOLE SHAREHOLDER-OFFICER OR ONE OF THE TWO OR BOTH EXECUTIVE OFFICERS-SHAREHOLDERS OF THE CORPORATION FROM SUCH COVERAGE To: CHAIRMAN, WORKERS' COMPENSATION BOARD To: (Print nameName and address of insuranceof carrier here) (Print and Address Insurance Carrier Here) THIS REVOCATION IS EFFECTIVE 30 DAYS AFTER THE DATE FILED WITH THE CHAIRMAN WORKERS' COMPENSATION BOARD.

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