1. (a) A corporation or limited liability company may elect to exclude 3 or fewer executive officers or members pursuant to RSA 281-A:18-a. This shall be done by the appropriate party, as explained below, completing and filing the “Exclusion of Executive Officers or Member” form 6WCex (7/2015) contained in appendix II.
2. (b) Only Carriers or NCCI on a carrier’s behalf shall complete and file with the department an “Exclusion of Executive Officers or Members” form 6WCex (7/2015) contained in appendix II. Any filing from another entity shall not be valid.
3. (c) This form shall not be valid unless there is a “Notice of Workers Compensation Insurance Coverage” form 6WC (4/2008) contained in appendix II already on file at the department with the same named employer.
4. (d) If the “Exclusion of Executive Officers or Members” form 6WCex (7/2015) contained in appendix II is not on file at the department, the executive officers or members shall not be excluded.
5. (e) The carrier shall forward a copy of the “Exclusion of Executive Officers or Members” form 6WCex (7/2015) contained in appendix II to each officer or member listed on the form by certified mail.
6. (f) If there is a change of carrier, a new “Exclusion of Executive Officers or Members” 6WCex (7/2015) contained in appendix II form shall be completed and filed by the new carrier.
7. (g) All officers or members to be excluded shall be listed on each new filing of the “Exclusion of Executive Officers or Members” form 6WCex (7/2015) contained in appendix II. Failure to complete the form accurately and fully shall negate the entire form. Each time an “Exclusion of Executive Officers or Members” form 6WCex (7/2015) contained in appendix II is completed and filed, a copy shall be sent to the listed executive officers or members by certified mail.
8. (h) When all of the excluded officers or members elect to be covered, a new “Exclusion of Executive Officers or Members” form 6WCex (7/2015) contained in appendix II shall be completed and filed.
9. (i) In the event of an injury, the “Exclusion of Executive Officers or Members” form 6WCex (7/2015) contained in appendix II that was on file with the department on the date of injury shall be the determining document as to whether that employee is excluded.
10. (j) Each filing of an “Exclusion of Executive Officers or Members” form 6WCex (7/2015) contained in appendix II that was on file of the department on the date of injury shall be the determining document as to whether that employee is excluded.
11. (k) Those executive officers or members who elect to be excluded under “Exclusion of Executive Officers or Members” form 6WCex (7/2015) contained in appendix II shall not be considered uninsured employees of a subcontractor under RSA 281-A:18.

Source. #11065, eff 4-1-16 (from Lab 306.04)