ACORD 171AK InstructionsACORD 171 AK (6/98) - Alaska Petition for Executive Officer WaiverUse this form to notify the Alaska Department of Labor, Workers Compensation Division that an executive officer of a corporation elects to be excluded from workers compensation insurance coverage. Instructions for Petition for Executive Officer Waiver A completed Petition for Executive Officer Waiver (Form 07-6131) must be submitted to: Alaska Department of Labor Fee schedule for a waiver is: Initial Petition none Amended Waiver $10.00 Copy of Waiver $ 2.00 Telephone: (907) 465-2790 Facsimile: (907) 465-2797 No. 1. Corporate name as it appears on the
Certificate of Incorporation. No. 3. Number of employees includes the executive officers requesting the waiver. Under the Alaska Workers' Compensation Act, the elected or appointed executive officers of a corporation are considered employees, therefore insurance needs to be provided unless a waiver is obtained. No. 4. The name and home address of each officer for whom an Executive Officer Waiver is requested. No. 5. Prior to signing the petition each officer requesting a waiver must have read this item and understand that his/her rights to benefits under the Alaska Workers' Compensation Act are being waived. All attachments must be submitted prior to a waiver being issued. No. 6. Name of person submitting the petition should be printed and need not be someone who is requesting a waiver. If questions arise, the Division will contact that person. Date the Petition is submitted. A waiver cannot be approved until all information requested on the Petition is on file with the Workers' Compensation Division. If you have not received a waiver from our division within 45 days of submitting the Petition and information, you should contact our office at (907) 465-2790. A WAIVER CANNOT BE ISSUED RETROACTIVELY Sign up for Free Access to all ACORD forms. Return to Simply Easier ACORD Forms home page from ACORD 24 Instructions page.
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