ACORD 171AK Instructions

ACORD 171 AK (6/98) – Alaska Petition for Executive Officer Waiver

Use 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
Workers’ Compensation Division
P.O. Box 25512
Juneau, Alaska 99802-5512

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. 2. Corporate mailing address. This is the address here the original waiver should be mailed.

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.