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California ­ Exclusion of Coverage Officers and Directors

Named Insured Policy Number

Paid Officers and Directors of a Private Corporation that is 100% owned by the Corporate Officers and Directors can be excluded from coverage if they own a portion of the stock

Exclusion of Coverage Each individual officer or director wishing to be excluded from coverage under this corporation's Workers' Compensation Policy must complete the information below.

Ownership %

Printed Name

Signature

Title

Date

CA-OFFEXCL (4/07)

FirstComp is a registered trademark for Aspen Holdings, Inc. and its affiliates but not limited to those doing business as FirstComp Insurance Company, FirstComp Underwriters Group, Inc., FirstComp Insurance Agency, FirstComp Insurance Group, Pinebrook Insurance Group, and Pinebrook Insurance Agency.

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Microsoft Word - California Officer Exclusion 4-07.doc