Maryland Workers' Compensation Commission Exclusion Form
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Date Stamp - WCC Use Only

10 East Baltimore Street
Baltimore, Maryland 21202-1641
TEL: (410) 864-5100 or 1 (800) 492-0479
TTD (MD Relay Service): 1(800)735-2258

Pursuant to the provisions of Labor & Employment Article § 9-206 of the Annotated Code of Maryland,
officers or members of a Farm Corporation, Close Corporation, Professional Corporation, or Limited
Liability Company are covered employees if the officer or member provides a service for monetary
compensation. Such officers or members who satisfy the criteria of Labor & Employment Article
§ 9-206(b) may elect to become excluded from coverage by filing this Exclusion Form with the
To exercise this option, any officer or member from the aforementioned types of organizations wishing
to be excluded must sign this document. NOTE: By signing this Exclusion Form below, each
officer or member affirms under the penalties of perjury that the informati