DBA Name: ____________________________________________________ Account No: ____________________________
Voluntary Election of Coverage for Excluded Employment
Check the types of non-covered employment you wish to cover:
Other (Specify) ______________________________________________
Indicate the date you request coverage of excluded employment to be effective: __________________________________________
Signature and Title
If you represent a corporation and wish to have corporate officers covered,
all officers must be covered as a group.
This agreement, when approved, is binding for the remainder of the calendar year in which it is received and two additional years.
Coverage continues in effect on a yearly basis until either you or the Agency terminates the agreement in writing before March 15 of
the year for which the termination is requested. In the event your taxes become delinquent, the Agency reserves the right to cancel
your Voluntary Coverage election effective the quarter the taxes become delinquent.
Additional Worksites (See instructions on Page 2, Item 11)
Name (Doing Business As)
Mailing Address City State Zip
Physical Address City State Zip
Describe (IN DETAIL) the major product sold or service you provide in Alaska
% Gross Alaska income
from this activity:
Number of employees