The Workers Comp Exclusion Form is utilized in situations where statutory exemptions permit the exclusion of certain workers from standard compensation coverage under English and Welsh law. This document becomes necessary when alternative arrangements are made or when specific statutory exemptions apply. The form must carefully balance the employer's right to implement exclusions with the worker's statutory protections under the Employers' Liability (Compulsory Insurance) Act 1969 and related legislation. It serves as a formal record of the agreement and understanding between all parties regarding the modification of standard workers compensation coverage.
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1. Employee Information: Personal and employment details of the worker including name, address, employment status, and role
2. Scope of Exclusion: Detailed specification of which workers compensation coverage elements are being excluded
3. Acknowledgment of Rights: Worker's explicit confirmation of understanding their rights and the implications of the exclusion
4. Legal Compliance Statement: Confirmation that the exclusion complies with relevant legislation including the Employers' Liability Act 1969
5. Signature Block: Space for dated signatures from the employee, employer, and any required witnesses
1. Alternative Coverage Details: Section detailing any alternative insurance arrangements or coverage being provided in lieu of standard workers compensation
2. Time Limitation: Section specifying the duration of the exclusion if it is temporary or fixed-term
3. Special Circumstances: Description of specific situations or conditions that warrant this exclusion
1. Schedule A - Proof of Alternative Coverage: Documentation and details of alternative insurance arrangements if applicable
2. Schedule B - Risk Assessment: Detailed assessment of workplace risks relevant to the exclusion and mitigation measures
3. Appendix 1 - Statutory Rights Summary: Comprehensive summary of worker's statutory rights that remain in effect despite the exclusion
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