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City State of Ownership if Corporation Select Title from dropdown list I elect to not be covered under the provisions of the California Workers Compensation Law. I elect to revoke the previous rejection of Workers Compensation Coverage. SOLE PROPRIETOR GENERAL OR LIMITED PARTNERSHIP DBA or Partnership Name I elect to be covered under the provisions of the California Workers Compensation Law. I swear or affirm under penalty of perjury that the information contained on this form is true and...
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