Free FORM - Connecticut

Please TYPE or PRINT IN INK

Rev. 4-30-2009

State of Connecticut Workers Compensation Commission

Date filed in District

6B

Coverage Election by Employee who is an Officer of a Corporation, Manager of an LLC, or Member of a Multiple-Member LLC
Pursuant to Section 31-321 C.G.S., this notice must be served upon the Compensation Commissioner in person or by registered or certified mail.
(for WCC use only)

COVERAGE ELECTION
To the Compensation Commissioner for the
(district number)

Compensation District of Connecticut at

(city of compensation office)

and to
(name of employer)

of
(employers city/town)

, Employer:

I,

(name of employee)

, an Employee of

(exact name of corporation or LLC)

, located at

(complete address of corporation or LLC)

, and also the

of said Corporation or LLC,
(office held)

hereby elect to:

q q

BE EXCLUDED FROM COVERAGE

under the Workers Compensation Act pursuant to Section 31-275 of the Connecticut General Statutes from the provisions of Section 31-275 of the Connecticut General Statutes

REVOKE ANY PREVIOUS ELECTION OF EXCLUSION

AFFIRMATION
Section 31-284 of the Connecticut General Statutes requires that workers compensation insurance be obtained for all covered employees.

Dated on this
(number)

day of
(month)

, 20
(year)

.

Employee Signature Employee Address City/Town State Zip Code