Section Name
Field Name
Field and/or Section Description
TITLE
ACORD 171 DE (2006/01)
Delaware Executive Officer(s)
Exclusion
Use this form to notify the Delaware Accident Board that an officer of a corporation elects
not to be subject to the provisions of the Delaware Workers' Compensation Law and
waives any and all benefits and rights to which they might be entitled.
Name of Corporation
Enter the name of the corporation establishing the agreement with the executive officer
who elects not to be subject to the Delaware Workers' Compensation Law.
Federal Employee Identification
Number Field 1
Enter the first digit of the nine-digit Federal Employee Identification Number (FEIN).
Federal Employee Identification
Number Field 2
Enter the second digit of the nine-digit Federal Employee Identification Number (FEIN).
Federal Employee Identification
Number Field 3
Enter the third digit of the nine-digit Federal Employee Identification Number (FEIN).
Federal Employee Identification
Number Field 4
Enter the fourth digit of the nine-digit Federal Employee Identification Number (FEIN).
Federal Employee Identification
Number Field 5
Enter the fifth digit of the nine-digit Federal Employee Identification Number (FEIN).
Federal Employee Identification
Number Field 6
Enter the sixth digit of the nine-digit Federal Employee Identification Number (FEIN).
Federal Employee Identification
Number Field 7
Enter the seventh digit of the nine-digit Federal Employee Identification Number (FEIN).
Federal Employee Identification
Number Field 8
Enter the eighth digit of the nine-digit Federal Employee Identification Number (FEIN).
Federal Employee Identification
Number Field 9
Enter the ninth digit of the nine-digit Federal Employee Identification Number (FEIN).
Chief Executive Officer (President)
The Chief Executive Officer (President) of the above named corporation must sign the
form.
Date
Enter the date (MM/DD/YYYY) the Chief Executive Officer (President) signed the form.
1. Print Name
Print or type the name of the executive officer electing not to be subjected to the Delaware
Workers' Compensation Law.
Signature
The executive officer electing not be subject to the Delaware Workers' Compensation Law
must sign the form.
Date
Enter the date (MM/DD/YYYY) the executive officer electing not be subject to the
Delaware Workers' Compensation Law signed the form.
2. Print Name
Print or type the name of the executive officer electing not to be subjected to the Delaware
Workers' Compensation Law.
ACORD 171 DE (2006/01)
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Section Name
Field Name
Field and/or Section Description
Signature
The executive officer electing not be subject to the Delaware Workers' Compensation Law
must sign the form.
Date
Enter the date (MM/DD/YYYY) the executive officer electing not be subject to the
Delaware Workers' Compensation Law signed the form.
3. Print Name
Print or type the name of the executive officer electing not to be subjected to the Delaware
Workers' Compensation Law.
Signature
The executive officer electing not be subject to the Delaware Workers' Compensation Law
must sign the form.
Date
Enter the date (MM/DD/YYYY) the executive officer electing not be subject to the
Delaware Workers' Compensation Law signed the form.
4. Print Name
Print or type the name of the executive officer electing not to be subjected to the Delaware
Workers' Compensation Law.
Signature
The executive officer electing not be subject to the Delaware Workers' Compensation Law
must sign the form.
Date
Enter the date (MM/DD/YYYY) the executive officer electing not be subject to the
Delaware Workers' Compensation Law signed the form.
5. Print Name
Print or type the name of the executive officer electing not to be subjected to the Delaware
Workers' Compensation Law.
Signature
The executive officer electing not be subject to the Delaware Workers' Compensation Law
must sign the form.
Date
Enter the date (MM/DD/YYYY) the executive officer electing not be subject to the
Delaware Workers' Compensation Law signed the form.
6. Print Name
Print or type the name of the executive officer electing not to be subjected to the Delaware
Workers' Compensation Law.
Signature
The executive officer electing not be subject to the Delaware Workers' Compensation Law
must sign the form.
Date
Enter the date (MM/DD/YYYY) the executive officer electing not be subject to the
Delaware Workers' Compensation Law signed the form.
7. Print Name
Print or type the name of the executive officer electing not to be subjected to the Delaware
Workers' Compensation Law.
Signature
The executive officer electing not be subject to the Delaware Workers' Compensation Law
must sign the form.
Date
Enter the date (MM/DD/YYYY) the executive officer electing not be subject to the
Delaware Workers' Compensation Law signed the form.
8. Print Name
Print or type the name of the executive officer electing not to be subjected to the Delaware
Workers' Compensation Law.
ACORD 171 DE (2006/01)
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Section Name
Field Name
Field and/or Section Description
Signature
The executive officer electing not be subject to the Delaware Workers' Compensation Law
must sign the form.
Date
Enter the date (MM/DD/YYYY) the executive officer electing not be subject to the
Delaware Workers' Compensation Law signed the form.
ACORD 171 DE (2006/01)
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