Indiana Notice For Workers' Compensation And Occupational Disease Coverage
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NOTICE FOR WORKER’S COMPENSATION
AND OCCUPATIONAL DISEASES COVERAGE

INDIANA WORKER’S COMPENSATION BOARD
402 W Washington Street, Room W196
Indianapolis, IN 46204

State Form 36097 (R5 / 9-11)

INSTRUCTIONS: Please type or print. Incomplete or illegible forms will be returned. For current forms, go to www.in.gov/wcb.

Pursuant to IC 22-3-6-1(b) and 22-3-2-9, the Indiana Worker’s Compensation Board is hereby notified that the undersigned applicant
does hereby elect to be covered for worker’s compensation and occupational diseases under the law.
STATEMENT OF VOLUNTARY ELECTION [IC 22-3-6-1(b)]
Federal Identification number (not Social Security number)

Name of applicant
Address (number and street, city, state, and ZIP code)

I certify that I meet the criteria set out in IC 22-3-6-1 (b) (4), (5) or (9), as selected below:
(4) Sole Proprietor
(5) Partner
(9) Member or Manager of a Limited Liability Company
Name of business

Nature of business

Address (number and street, city,