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Get C105 51 2004-2024

THE SOLE SHAREHOLDER-OFFICER OR ONE OF THE TWO OR BOTH EXECUTIVE OFFICERS-SHAREHOLDERS OF THE CORPORATION FROM SUCH COVERAGE To: (Print (Print name and and address of insurance carrier here.) Name Address of Insurance Carrier Here) TAKE NOTICE that under the provisions of Section 54, subdivision 6, of the Workers' Compensation Law as amended, the corporation named below elects to exclude the executive officer(s) named below from coverage under the New York State Workers' Compensation Law with.

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