REFERENCE · 51 JURISDICTIONS · SOURCE-CHECKED THROUGH 2026-10-10

STATE FORMS
REFERENCE

For every state and the District of Columbia: the owner exemption, exclusion, or elective-coverage document, the agency that issues it, how it is filed, the fee, when it takes effect, and whether it renews. Where a state has no universal owner-exemption filing, that is stated plainly — it does not mean the state has no coverage rules. Every row links to the official source and shows the date it was last checked.

HOW TO READ THIS

“No universal form” means the owner rule is mostly statutory or handled through the insurance policy, not that coverage is optional. Some rows describe electing into coverage rather than out of it. Always confirm the current rule with the issuing agency before you file or change coverage — an exempt owner has no workers' compensation benefit for their own injury.

Download the full dataset: CSV · JSON — 51 rows, official source URL + source-check date per row. Attribution appreciated; see terms.

51 of 51 jurisdictions

Alabama

No universal form

Issuing body: Alabama Department of Labor, Workers’ Compensation Division
Filing method: No current state owner-exclusion filing; qualifying status is handled by statute and the insurance policy.
Fee: No separate filing fee verified
Note: Alabama DOL states that it no longer accepts the former WC-14/WC-15 corporate-officer inclusion/exclusion forms.
Effective: No current state filing date applies to the statutory owner treatment; policy elections take effect under the policy/endorsement.
Renewal: No state-form renewal cycle; review after ownership, entity, employee, or policy changes.

Alaska

No universal form

Issuing body: Alaska Department of Labor and Workforce Development, Workers’ Compensation Division
Filing method: No current state owner-waiver filing; qualifying owners are excluded by statute and may be specifically included through the policy.
Fee: No separate filing fee verified
Note: The former executive-officer waiver program was repealed effective August 1, 2019.
Effective: Statutory exclusion applies without an owner-exemption certificate; elective inclusion is tied to the policy period.
Renewal: No state-form renewal cycle; elective inclusion follows the policy period.

Arizona

No universal form

Issuing body: Industrial Commission of Arizona / workers’ compensation carrier
Filing method: No universal owner-exemption certificate. A.R.S. §23-961 provides (in a subsection recodified over time) a signed sole-proprietor waiver a sole proprietor can give the hiring business/insurer in the stated context; other inclusion/exclusion is handled by carrier endorsement.
Fee: No separate filing fee verified
Note: The ICA sole-proprietor/independent-contractor statement is a relationship/classification document, not a universal owner exemption. Under that provision, a business using a sole proprietor who has waived workers' comp rights is not liable for that sole proprietor's coverage or premiums.
Effective: Carrier endorsement controls any elective personal coverage; the §23-961 sole-proprietor waiver applies as stated in the statute; statutory exclusions do not wait for an exemption certificate.
Renewal: Tied to the policy/endorsement, the signed waiver, and ownership status; no universal state-form renewal interval.

Arkansas

AR-A

Application for Certificate of Non-Coverage

Issuing body: Arkansas Workers’ Compensation Commission
Filing method: Complete and notarize Form AR-A first. Submit the application package to AWCC by mail or deliver it in person; pay the $50 fee by check or money order with the form, or use AWCC’s separate online payment portal after the application and notarized affidavit are complete. If any screening answer is yes, the form directs the applicant to an insurance agent for further processing.
Fee: $50
Note: The certificate is personal to qualifying applicants and does not excuse coverage for hired employees. Form AR-A counts owners, qualifying full-time partners, part-time employees, and volunteers in its threshold questions; corporate officers use a carrier exclusion instead. Current AWCC materials say applications are generally processed within 10 working days.
Effective: On AWCC issuance/approval of the Certificate of Non-Coverage.
Renewal: No universal duration was located on the current application page; use the expiration shown on the issued certificate and refile as required.

California

13L-50 (CSLB "Order Form #32")

Exemption from Workers’ Compensation (CSLB license record)

Issuing body: California Contractors State License Board
Filing method: Use the CSLB online exemption service, or file the printable Form 13L-50 (identified as "Order Form #32" on the CSLB requirements page) with the license/application record.
Fee: No separate filing fee verified
Note: This is the contractor-license no-employee exemption — the licensee certifies under penalty of perjury that it employs no one subject to California workers' comp law. It is separate from the Labor Code §3352 carrier waiver for qualifying corporate/LLC owners, and some contractor classifications (C-8, C-20, C-22, C-39, C-61/D-49) cannot use the ordinary no-employee CSLB exemption.
Effective: When CSLB accepts and records the exemption for the license/application.
Renewal: No fixed annual renewal interval; the exemption ceases to fit when the licensee hires employees or no longer meets CSLB eligibility.

Colorado

WC 43

Rejection of Coverage (Notice of Election to Reject Workers’ Compensation Coverage)

Issuing body: Colorado Division of Workers’ Compensation / workers’ compensation insurer
Filing method: Complete Form WC 43 and give it to the workers’ compensation insurer; if there is no insurer, file it with the Division (the individual’s signature must be notarized when filed with the Division). Since January 1, 2025 an owner with no employees can submit WC 43 through the Division’s online Rejection of Coverage service.
Fee: No separate filing fee verified
Note: A corporate officer or LLC member must hold at least a 10% ownership interest and participate in the business’s daily operations or management to reject. The rejection is personal and does not remove the company’s duty to cover its employees; the rejecting owner gives up all Workers’ Compensation Act benefits and C.R.S. §8-41-401(3) may cap any recovery at $15,000. WC 43 now also covers construction sole proprietors and partners — the former WC 45 was discontinued. Verify filed status in DOWC’s rejection search; a missing search result alone does not prove no filing because database processing can take several days.
Effective: The next business day following receipt of the notice by the insurance carrier, or by the Division if there is no carrier (C.R.S. §8-41-202; 7 CCR 1101-3).
Renewal: No fixed renewal interval; the rejection continues until the owner/member files a revised election, or the entity obtains a policy covering that person.

Connecticut

Form 6B

Coverage Election by Employee Who Is an Officer of a Corporation or a Manager of an LLC

Issuing body: Connecticut Workers’ Compensation Commission
Filing method: File Form 6B electronically through the WCC electronic form submission service, or by mail/email (WCC.Forms@ct.gov) to the Office of the Chairperson; Form 6B-1 and Form 75 cover other owner types.
Fee: No separate filing fee verified
Note: WCC accepts the form for filing purposes; the filer remains responsible for eligibility and accuracy. Keep the electronic confirmation or date-stamped copy.
Effective: On Commission filing/date stamp of the election for the covered category.
Renewal: No fixed annual renewal; use the same election form to revoke the prior exclusion, and refile when the election facts change.

Delaware

Form C

Workers’ Compensation Coverage Election Record (recommended Form C)

Issuing body: Delaware Department of Insurance / workers’ compensation carrier
Filing method: Written notice and policy endorsement through the carrier; Delaware Form C is a recommended record of the election.
Fee: No separate filing fee verified
Note: Form C is not a state-issued exemption certificate. Contractor-specific exclusions and proof-retention rules are stricter than the ordinary owner election framework.
Effective: After the insurer or its agent receives the written request, with the election implemented through the applicable policy inception/renewal endorsement mechanics.
Renewal: No annual state refiling; the election stays in the policy record until changed at a permitted policy inception or renewal.

District of Columbia

No universal form

Issuing body: District of Columbia Department of Employment Services, Office of Workers’ Compensation
Filing method: No universal owner-exemption filing is published for the sole-proprietor path; D.C. DOES states sole proprietors are not covered while employers with one or more employees must obtain coverage for employees.
Fee: No separate filing fee verified
Note: D.C. does not use a general owner-exemption certificate comparable to Florida or Tennessee for the sole-proprietor rule. Construction-permit proof requirements remain separate, and LLC/corporate-officer treatment must be checked against the Act and current DOES guidance.
Effective: No exemption filing date applies to the sole-proprietor exclusion described by DOES; ordinary employer coverage duties begin when covered employees are present.
Renewal: No owner-exemption renewal cycle for the sole-proprietor exclusion; re-check the Act/DOES after entity, ownership, employee, or permit-status changes.

Florida

DWC-250

Notice of Election to Be Exempt

Issuing body: Florida Department of Financial Services, Division of Workers’ Compensation
Filing method: Online DWC Notice of Election to Be Exempt system.
Fee: $50 plus $1 convenience fee (construction); $0 (non-construction)
Note: The $50 construction exemption is limited to active officers/members with at least 10% ownership, with a three-person cap across affiliated entities. Non-construction corporations have no ownership-percentage rule or fee; non-construction LLC members need at least 10% ownership and are capped at 10. The online service handles application, renewal, status lookup, and certificate printing.
Effective: When issued by the Division or 30 days after receipt, whichever occurs first, subject to the statute’s special early-policy rule.
Renewal: 2 years; renewal application is required. Florida sends an expiration notice at least 60 days before expiration.

Georgia

WC-10

Notice of Election or Rejection of Workers’ Compensation Coverage

Issuing body: Georgia State Board of Workers’ Compensation
Filing method: File with the current insurer; when no insurer applies in the stated owner-only scenario, file with the Board.
Fee: No separate filing fee verified
Note: Corporate officers/LLC members still count toward Georgia’s employee threshold even when they reject personal coverage. The form is not a waiver of the employer’s coverage duty.
Effective: Effective on filing with the insurer, or with the Board when the no-insurer filing route applies.
Renewal: No fixed annual renewal; remains until revoked/superseded by a later WC-10 or relevant policy/status change.

Hawaii

No universal form

Issuing body: Hawaii Department of Labor and Industrial Relations, Disability Compensation Division
Filing method: No universal owner-exemption certificate identified; qualifying owner status is handled through statutory employee exclusions and elective coverage rules.
Fee: No separate filing fee verified
Note: Hawaii generally requires coverage when there is one or more employee; owner exclusions are entity/ownership-specific rather than a blanket form.
Effective: No owner-specific filing effective date identified.
Renewal: No owner-specific state-form renewal cycle.

Idaho

IC-52

Election of Coverage

Issuing body: Idaho Industrial Commission / workers’ compensation carrier
Filing method: Written declaration through the insurance company and employer; carriers report the election or revocation using IC-52 or substantially similar format.
Fee: No separate filing fee verified
Note: IC-52 elects coverage for otherwise exempt owners and other exempt categories. Idaho does not recognize a general owner waiver allowing required employee coverage to be avoided.
Effective: Effective date stated in the election/coverage filing and policy record.
Renewal: Continues according to the election/policy until revoked using IC-52 or equivalent carrier reporting.

Illinois

No universal form

Issuing body: Illinois Workers’ Compensation Commission / workers’ compensation carrier
Filing method: No IWCC owner opt-out form. Qualifying owner/officer opt-out is handled by written notice to the carrier.
Fee: No separate filing fee verified
Note: The personal opt-out is separate from the employer’s duty to insure employees; construction and extra-hazardous work require separate analysis.
Effective: For qualifying corporate officers, effective on carrier receipt of the withdrawal notice.
Renewal: No state-form renewal cycle; tied to the written carrier election and policy/status changes.

Indiana

WCE-1 / State Form 45899

Worker’s Compensation Clearance Certificate Application

Issuing body: Worker’s Compensation Board of Indiana
Filing method: Submit the current WCE-1 clearance application with required payment through the filing method stated on the current Board form.
Fee: $20
Note: The certificate is not valid without the Board stamp. It is a clearance mechanism for listed independent contractors/sole proprietors/partners/LLC members or managers and does not replace coverage for employees.
Effective: When stamped/approved by the Worker’s Compensation Board.
Renewal: 1 year; annual reapplication is required.

Iowa

Form

Nonelection of Workers’ Compensation or Employers’ Liability Coverage

Issuing body: Iowa Department of Inspections, Appeals, and Licensing, Workers’ Compensation Division
Filing method: If no policy exists, use DIAL’s online nonelection filing with two disinterested witnesses; if a policy exists, attach the nonelection to the policy rather than file it with WCD.
Fee: No separate filing fee verified
Note: Available to proprietors, LLCs, LLPs, and partnerships. Corporate officers use the separate rejection process. Nonelection cannot be required as a condition of employment.
Effective: When the written nonelection is attached to the policy, or when the no-policy online filing is completed with WCD; corporate officers use the separate rejection process.
Renewal: No periodic renewal. The nonelection/rejection continues until terminated; a nonelection termination does not affect an injury or disease occurring within one week after the termination notice is filed.

Kansas

Form

Workers’ Compensation Election (OSCAR filing)

Issuing body: Kansas Department of Labor, Division of Workers Compensation
Filing method: Electronic election through KDOL’s OSCAR system.
Fee: No separate filing fee verified
Note: Kansas allows qualifying non-covered employers/owners and 10%+ corporate owner-employees to make coverage elections; the employer’s underlying subjectivity/payroll rules remain separate.
Effective: KDOL requires the election to be submitted electronically through OSCAR; the public overview does not publish one universal effective-date formula for every election type.
Renewal: No universal annual renewal interval is published for every OSCAR election type; update or terminate the election under the applicable filing/policy procedure when the coverage choice changes.

Kentucky

Form 4

Employee’s Notice of Rejection of Workers’ Compensation Act

Issuing body: Kentucky Department of Workers’ Claims
Filing method: Original notarized Form 4 is given to the employer and filed with the Department of Workers’ Claims; copies/fax do not satisfy the regulation.
Fee: No separate filing fee verified
Note: Corporate officers are employees and may reject personal coverage with Form 4. Owner-only partnership/LLC treatment follows separate statutory rules.
Effective: When the Department receives the fully completed original Form 4.
Renewal: No annual renewal; remains until withdrawn using Form 5 or superseded by a valid later election.

Louisiana

No universal form

Issuing body: Louisiana Workforce Commission / workers’ compensation insurer or group fund
Filing method: No Louisiana state exemption certificate. Qualifying owners use written non-election with the insurer/group fund under state law.
Fee: No separate filing fee verified
Note: Louisiana expressly does not issue a state exemption certificate; the written carrier/fund record is the relevant personal non-election evidence.
Effective: As provided by the written insurer/group-fund non-election and policy record.
Renewal: Tied to the written non-election/policy until revoked or status changes; no state certificate renewal cycle.

Maine

WCB-2C

Application for Waiver

Issuing body: Maine Workers’ Compensation Board
Filing method: Submit Form WCB-2C to the Workers’ Compensation Board for approval.
Fee: No separate filing fee verified
Note: Owners of sole proprietorships, partnerships and LLCs generally do not need a waiver for themselves; WCB-2C is important for qualifying corporate owners and certain relatives.
Effective: Not valid until approved by the Board.
Renewal: Until revoked/rescinded; the form allows revocation on 30 days’ written notice to the Board and employer.

Maryland

IC-16

Exclusion Form

Issuing body: Maryland Workers’ Compensation Commission
Filing method: Use CompHub/current Commission filing workflow for §9-206 exclusions; retain/provide the IC-16 election record as directed, including insurer copy when applicable.
Fee: No separate filing fee verified
Note: Qualifying compensated officers/LLC members begin as covered employees and may elect exclusion under specific ownership/category rules. Sole proprietors/partners use different elective-in rules.
Effective: On acceptance/recording of the §9-206 exclusion filing under the Commission workflow.
Renewal: No fixed universal renewal interval identified; refile/review when ownership, entity, officer/member status, or policy facts change.

Massachusetts

Form 153

Affidavit of Exemption for Certain Corporate Officers or Directors

Issuing body: Massachusetts Department of Industrial Accidents
Filing method: Submit by mail, in person, fax, or email to DIA Office of Investigations — Form 153.
Fee: No separate filing fee verified
Note: Available only to qualifying corporate officers/directors owning at least 25%; it does not exempt non-officer employees.
Effective: After DIA approval of the exemption request.
Renewal: Annual carrier confirmation before policy renewal; a new Form 153 is required after specified ownership/officer status changes.

Michigan

WC-337

Notice of Exclusion

Issuing body: Michigan Workers’ Disability Compensation Agency
Filing method: File the current WC-337 with the Agency under its owner-only exclusion process.
Fee: No separate filing fee verified
Note: WC-337 is not a generic owner certificate. Mich. Admin. Code R 408.41b makes the exclusion effective upon Agency receipt, but the Agency form also states it is not valid unless stamped as on file — so keep the stamped copy. Businesses with employees generally handle qualifying owner exclusions through the policy instead.
Effective: Upon receipt by the Michigan Workers’ Disability Compensation Agency (Mich. Admin. Code R 408.41b); the filed, stamped form is the proof.
Renewal: No fixed interval stated on the current WC-337 landing page; refile when the exclusion facts or Agency requirements change.

Minnesota

No universal form

Issuing body: Minnesota Department of Labor and Industry / workers’ compensation insurer
Filing method: No universal owner-exemption certificate; common owner exclusions arise from statute/entity/ownership conditions, with elective coverage handled through the insurer.
Fee: No separate filing fee verified
Note: Certain relative-election forms exist, but they are not a general owner exemption form. Effective January 1, 2026 (2025 session law), a construction subcontractor buying a 'zero estimated exposure' / if-any policy must give its insurer a sworn no-employee attestation and give written notice plus a policy copy to anyone it contracts with; the general contractor must keep that notice and policy for three years, and insurers must publicly report zero-exposure policies.
Effective: Statutory exclusion does not wait for a general owner filing; elective coverage follows the policy/endorsement.
Renewal: No universal owner-form renewal cycle; policy elections follow the policy and status changes.

Mississippi

No universal form

Issuing body: Mississippi Workers’ Compensation Commission
Filing method: No current universal MWCC owner-exemption form identified; owner treatment is statutory/entity-specific and voluntary coverage agreements are handled separately.
Fee: No separate filing fee verified
Note: Current official MWCC material does not support inventing a form number, fee, or annual owner-exemption renewal cycle.
Effective: No owner-specific state filing effective rule identified.
Renewal: No owner-specific state-form renewal cycle identified.

Missouri

Form

Notice of Election to Withdraw (qualifying two-owner corporation)

Issuing body: Missouri Division of Workers’ Compensation
Filing method: File the corporation’s notice of election to withdraw with the Division; current DWC guidance directs applicants to the Division for the required paperwork.
Fee: No separate filing fee verified
Note: This corporate path is limited to a corporation with no more than two owners who are also its only employees. LLC-member rejection is instead a written policy/insurer form.
Effective: The qualifying corporation’s election takes effect from the date the notice is filed with the Division.
Renewal: Continues until the corporation withdraws the election; withdrawal is effective 30 days after filing or a later stated date.

Montana

ICEC

Independent Contractor Exemption Certificate Application

Issuing body: Montana Department of Labor & Industry
Filing method: Apply online through the Montana contractor portal or submit the current ICEC application and supporting business documentation.
Fee: $125 (non-refundable)
Note: ICEC is an independent-contractor status certificate, not a blanket owner waiver for a business or its employees. The $125 fee is non-refundable and is charged again on each renewal. Montana is moving ICEC applications and renewals online in August 2026.
Effective: On DLI approval/issuance of the ICEC.
Renewal: 2 years; a renewal application with the $125 fee is required to keep the ICEC current (Mont. Admin. R. 24.35.121).

Nebraska

No universal form

Issuing body: Nebraska workers’ compensation insurer / employer
Filing method: No universal owner-exemption certificate. Qualifying executive officers are outside coverage by default at the statutory ownership threshold; exempt owners may elect coverage in writing through the corporation/insurer.
Fee: No separate filing fee verified
Note: For the statutory owner election, the written notice is filed with the corporation/insurer rather than a state exemption registry.
Effective: Elective owner coverage becomes effective on insurer receipt of the written election.
Renewal: Continues for the current and subsequent policies issued by that insurer until written termination or the insurer ceases coverage.

Nevada

D-45

Election of Coverage by Employer — Sole Proprietor Coverage

Issuing body: Nevada Department of Business and Industry, Division of Industrial Relations / insurer
Filing method: Submit the applicable Nevada election/rejection form through the insurer and state reporting process; D-45 is the sole-proprietor elective-coverage form.
Fee: No separate filing fee verified
Note: D-45 elects personal coverage; it is not an exemption certificate. Corporate officers/LLC managers use the separate statutory rejection framework and related D-43/D-44 forms.
Effective: Effective date stated on the election/rejection and policy filing.
Renewal: Continues until the election/rejection is withdrawn, rescinded by changed pay/status, or superseded by a later filing.

New Hampshire

6WCex

Exclusion of Executive Officers or Members

Issuing body: New Hampshire Department of Labor / workers’ compensation carrier
Filing method: The carrier files Form 6WCex; an underlying Notice of Workers Compensation Insurance Coverage (6WC) for the same employer must already be on file.
Fee: No separate filing fee verified
Note: If 6WCex is not on file, the listed executive officers/members are not excluded. A carrier change requires a new 6WCex.
Effective: On proper filing with the Department under Lab 306; the filed form in effect controls the exclusion.
Renewal: No fixed annual renewal; a new 6WCex is required when the carrier changes or the excluded roster/election changes.

New Jersey

No universal form

Issuing body: New Jersey Department of Labor and Workforce Development / workers’ compensation insurer
Filing method: No universal owner-exemption certificate. Sole proprietors, partners, and LLC members may elect personal coverage when a policy is purchased or renewed; corporate officers are generally employees.
Fee: No separate filing fee verified
Note: Owner personal coverage elections do not remove the entity’s separate duty to insure covered workers.
Effective: Elective personal coverage takes effect through the policy/endorsement.
Renewal: Tied to policy purchase/renewal and endorsement status.

New Mexico

Form

Executive Employee Affirmative Election

Issuing body: New Mexico Workers’ Compensation Administration
Filing method: File the applicable WCA insurance-coverage election form; a separate CID Sole Proprietor Affirmative Election applies to the qualifying construction-sole-proprietor lane.
Fee: No separate filing fee verified
Note: Executive owners may still count toward New Mexico’s employee threshold even when personally excluded. Do not substitute the construction sole-proprietor form for the executive-owner election.
Effective: On WCA filing/acceptance of the affirmative election as provided by the form.
Renewal: Continues until revoked; the current Revocation of Prior Election form states a 30-day delay before revocation becomes effective.

New York

CE-200

Certificate of Attestation of Exemption

Issuing body: New York State Workers’ Compensation Board
Filing method: Request the CE-200 online through New York Business Express (businessexpress.ny.gov) or the WCB online exemption service, for a specific government license, permit, or contract.
Fee: No separate filing fee verified
Note: CE-200 is transaction-specific proof for government licensing/permit/contract purposes. It is not a private-business owner exemption certificate and is separate from C-105.51 officer exclusions inside insured policies.
Effective: On issuance for the specific government transaction identified on the certificate.
Renewal: No periodic renewal; a new CE-200 is required for each separate license, permit, or contract when the exemption conditions are met.

North Carolina

No universal form

Issuing body: North Carolina Industrial Commission / workers’ compensation insurer
Filing method: No state owner-exemption certificate. Corporate-officer exclusion is written into the insurance contract; sole proprietors, partners, and LLC members may elect personal coverage through insurer notice.
Fee: No separate filing fee verified
Note: Corporate officers still count toward the general employee threshold even when personally excluded.
Effective: Policy endorsement/insurer notice controls the personal election.
Renewal: Corporate-officer exclusion lasts for the insurance contract period; other owner elections are tied to insurer/policy records.

North Dakota

Form

Elective Coverage Application and Contract

Issuing body: North Dakota Workforce Safety & Insurance
Filing method: Complete the WSI application for insurance and elective coverage contract when required; coordinate with the account underwriter for owner/officer elective coverage.
Fee: No separate filing fee verified
Note: Owners, partners and corporate officers are exempt from Title 65 personal coverage unless elective coverage is purchased. Verification of nonemployment is a separate proof process.
Effective: When WSI approves the completed, signed application and elective coverage contract, when applicable.
Renewal: Continues under the WSI elective-coverage contract until cancelled or changed under WSI procedures; elective-only accounts are eligible for annual payroll reporting rather than a separate exemption renewal.

Ohio

U-3 / U-3S

Application for Ohio Workers’ Compensation Coverage / Elective Coverage Change

Issuing body: Ohio Bureau of Workers’ Compensation
Filing method: Use U-3 when opening coverage and U-3S to add or cancel elective owner coverage after the policy is established.
Fee: $120 non-refundable initial U-3 policy application fee; no separate U-3S filing fee verified
Note: Ohio’s listed owners are generally asking to elect personal coverage, not to obtain an exemption certificate. Premium applies when elective coverage is added.
Effective: For a later U-3S election, elective coverage is added on the date BWC receives the completed application and applicable premiums are charged; initial U-3 coverage begins when the completed application and $120 fee are successfully submitted/received.
Renewal: Elective coverage renews each July and continues until BWC receives a written cancellation request or coverage otherwise lapses/changes.

Oklahoma

No universal form

Issuing body: Oklahoma Workers’ Compensation Commission / workers’ compensation insurer
Filing method: No universal Oklahoma owner-exemption certificate; qualifying owners are excluded by statute and may affirmatively elect coverage.
Fee: No separate filing fee verified
Note: OMES Form D312 is a state-procurement affidavit and is not the general private-sector owner exemption form.
Effective: Statutory owner exclusion applies without a universal state exemption filing; elective inclusion follows the policy/election.
Renewal: No universal owner-form renewal cycle; elective coverage follows the policy/election.

Oregon

No universal form

Issuing body: Oregon Workers’ Compensation Division / workers’ compensation insurer
Filing method: No universal owner-exemption certificate; Oregon uses subject/nonsubject-worker rules under ORS 656.027, with construction-specific limits.
Fee: No separate filing fee verified
Note: Owner treatment depends on entity, ownership and work performed. Direct construction work can change partner/LLC/member treatment.
Effective: Statutory nonsubject status applies without a universal owner filing; elective coverage follows the policy.
Renewal: No universal owner-form renewal cycle.

Pennsylvania

LIBC-509 + LIBC-513

Executive Officer Exclusion Application and Declaration

Issuing body: Pennsylvania Department of Labor & Industry / insurer
Filing method: Submit LIBC-509 with an LIBC-513 declaration for each eligible officer, electronically or by paper. File with the carrier when the corporation insures other employees; if it has no other employees, file with DLI’s Bureau of Workers’ Compensation Compliance Section.
Fee: No separate filing fee verified
Note: For-profit S-corporations may request exclusion for officers with any ownership interest; C-corporation officers need at least 5%. Paper filings include a declaration for every officer with an ownership interest, and the declared ownership shares must total 100%. These forms are for corporate officers, not sole proprietors, partners, or LLC members.
Effective: On acceptance/endorsement of the qualifying executive-officer exclusion under the applicable carrier/DLI workflow.
Renewal: Tied to the exclusion/policy and officer/ownership facts; refile when the relevant policy or eligibility changes.

Rhode Island

DWC-11

Notice of Claim of Common Law Rights

Issuing body: Rhode Island Department of Labor and Training, Division of Workers’ Compensation
Filing method: File the notarized state DWC-11 waiver form with DLT; current forms are on DLT’s Forms & Applications page.
Fee: A filing fee applies and must accompany the form — DLT increased the waiver fee in 2024 (the older statutory figure was $5). Confirm the current amount printed on the DLT DWC-11 before filing.
Note: DWC-11 is the corporate-officer / common-law-right waiver and must be signed before a notary. DWC-11-IC is a separate independent-contractor designation (no fee) and should not be substituted for the owner/officer waiver.
Effective: On DLT filing/acceptance of the DWC-11 as provided by the current form/statute.
Renewal: No fixed annual renewal stated for DWC-11; it remains until rescinded using DWC-11R or the qualifying status changes.

South Carolina

Form 5

Corporate Officer Notice to Reject

Issuing body: South Carolina Workers’ Compensation Commission
Filing method: Corporate officer signs/notarizes Form 5 and provides it to the employer and employer’s insurance carrier as required by the form/regulation.
Fee: $0
Note: Form 5 is for corporate officers; no general LLC-member Form 5 path is inferred. The Commission forms list currently shows no filing fee for Form 5.
Effective: No earlier than the day after the corporate officer signs the notice, subject to the required notice mechanics.
Renewal: No fixed annual renewal; remains until revoked/superseded or policy/status facts change under the applicable rules.

South Dakota

No universal form

Issuing body: South Dakota Department of Labor and Regulation / workers’ compensation insurer
Filing method: No universal state owner-exemption certificate; South Dakota does not require every employer to carry workers’ compensation by a blanket statewide mandate. Owner/officer rejection, where relevant, is handled under the policy/statute.
Fee: No separate filing fee verified
Note: The Independent Contractor Affidavit of Exempt Status is a classification document, not a universal owner waiver.
Effective: No universal owner-specific filing effective rule.
Renewal: No universal owner-specific state-form renewal cycle.

Tennessee

LB-4523

Initial Workers’ Compensation Exemption Registration Application

Issuing body: Tennessee Bureau of Workers’ Compensation
Filing method: E-file, print-and-mail, paper submission, or walk-in to the Exemption Registry with the required fee.
Fee: $50 with active contractor license; $100 without active contractor license
Note: The registry is for eligible construction business owners and exempts only the listed individual, not employees or the business entity. Subsequent registration uses LB-4530 and costs $20.
Effective: On Bureau approval/registration in the Workers’ Compensation Exemption Registry.
Renewal: 2 years; renewal opens 60 days before expiration. Subsequent exemption registration fee is $20.

Texas

No universal form

Issuing body: Texas Department of Insurance, Division of Workers’ Compensation / workers’ compensation insurer
Filing method: No general owner-exemption certificate. Most private employers may choose whether to carry workers’ compensation; owner/officer exclusions inside an insured policy are handled by the policy/endorsement.
Fee: No separate filing fee verified
Note: DWC Form-005 is a non-subscriber notice, not an owner exemption certificate. Public-project construction is a separate statutory exception to the otherwise optional private-employer framework.
Effective: Policy exclusions take effect under the applicable endorsement; non-subscriber reporting follows its own filing rules.
Renewal: Tied to the policy/endorsement or non-subscriber reporting status; no owner-certificate renewal cycle.

Utah

WCCW

Workers’ Compensation Coverage Waiver

Issuing body: Utah Labor Commission, Division of Industrial Accidents
Filing method: Apply through the Utah WCCW online process.
Fee: $50 (nonrefundable)
Note: WCCW is an owner/no-employee waiver for qualifying owners and certain independent contractors. Owner-operator motor carriers have additional occupational-accident proof requirements.
Effective: On Labor Commission approval/issuance of the waiver.
Renewal: 1 year; reapply for a new waiver to continue after expiration. The waiver may be revoked earlier if eligibility is lost.

Vermont

Form 29

Application to Exclude Corporate Officers or LLC Members From Workers’ Compensation Coverage

Issuing body: Vermont Department of Labor
Filing method: Submit Form 29 with required organizational documentation for Commissioner approval.
Fee: No separate filing fee verified
Note: Form 29 applies to qualifying corporate officers and LLC managers/members; sole proprietors/partners use a different statutory framework.
Effective: After Commissioner approval, and no earlier than the date the Commissioner received a complete application with the required minutes or affidavit.
Renewal: Until rescinded; the approved exclusion remains effective without a fixed annual renewal interval.

Virginia

Form 16A

Rejection of Coverage

Issuing body: Virginia Workers’ Compensation Commission
Filing method: File electronically, by mail, or by fax with the Commission; a valid workers’ compensation policy is required for this rejection route.
Fee: No separate filing fee verified
Note: Form 16A is for an executive officer or elected/appointed LLC manager who meets the rule; an LLC member title alone is not enough. It rejects accident/death coverage but does not reject occupational-disease coverage.
Effective: At the later statutory point tied to policy inception and delivery/filing of the rejection notice.
Renewal: Continues until revoked with Form 17A.

Washington

F213-042-000

Application for Elective Coverage

Issuing body: Washington State Department of Labor & Industries
Filing method: Submit the Application for Elective Coverage to L&I for an otherwise excluded owner/person.
Fee: No separate filing fee verified
Note: Washington owner exclusions arise from statute/entity/management structure; F213-042-000 elects coverage and does not create the exclusion.
Effective: 12:01 a.m. on the day after L&I receives the application unless a later effective date is requested/accepted.
Renewal: Continues until cancelled under L&I elective-coverage procedures.

West Virginia

Form

Application for Verification of Statutory Exemption from WV Workers’ Compensation Coverage

Issuing body: West Virginia Offices of the Insurance Commissioner, Employer Coverage Unit
Filing method: Submit the notarized exemption application to the Employer Coverage Unit and pay the required application fee.
Fee: $25
Note: This is a full employer statutory-exemption verification process. A personal owner/officer exclusion alone does not make the business fully exempt.
Effective: On the effective date assigned by the Office of the Insurance Commissioner after review/approval.
Renewal: No universal renewal interval stated on the current application page; reapply/reverify when the employer’s exemption facts materially change.

Wisconsin

WKC-7602-E

Corporate Officer Option Notice

Issuing body: Wisconsin Department of Workforce Development, Worker’s Compensation Division
Filing method: File the Corporate Officer Option Notice with the Wisconsin Worker’s Compensation Division.
Fee: No separate filing fee verified
Note: This narrow option applies to a closely held corporation with no more than two corporate officers and no other employees. It is not a general owner exclusion for every corporation/LLC.
Effective: On filing/acceptance of the option notice for a qualifying corporation.
Renewal: Until rescinded in writing to the Division or the corporation obtains a workers’ compensation insurance policy.

Wyoming

Form

Affidavit of Coverage

Issuing body: Wyoming Department of Workforce Services, Workers’ Compensation Employer Services
Filing method: Make a written request using the Affidavit of Coverage supplied by the Division; Employer Services provides the form/process.
Fee: No separate filing fee verified
Note: Owners are not automatically covered. Corporate officers, LLC members, sole proprietors and partners may elect personal coverage. Corporate officer coverage is tied to the office/position, not the individual.
Effective: On the Division-approved effective date shown for the elected coverage.
Renewal: Owner/officer elective coverage is subject to Wyoming’s minimum coverage commitment; current employer guidance requires status updates, including officer changes within 30 days.