ACORD 171GA Instructions

ACORD 171 GA (2001/03) – Georgia State Board of Workers Compensation
Notice of Election or Rejection of Workers’ Compensation Coverage

Use this form when:

1. A corporate officer or limited liability company member elects to reject workers compensation insurance coverage, or desires to revoke a previous rejection of coverage;

2. A sole proprietor or partner elects to be included as a coveredemployee, or desires to revoke a previous election;

3. A farm labor employer elects to provide coverage for farm laborers, or desires to revoke a previous election.

This form must be retained by the workers compensation insurancecarrier.

The text of this form is identical to the Georgia State Board of Workers’ Compensation form WC – 10 (7/99).