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Rev. 4-30-2009

State of Connecticut Workers Compensation Commission

Date filed in District

6B-1
(for WCC use only)

Coverage Election by Employees who are Members of a Partnership
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. If there are more than four partners, attach additional sheets for names, signatures, and social security numbers.

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

Compensation District of Connecticut at

(city of compensation office)

and to
(name of partnership)

of

(complete address of partnership)

having a total of

(number)

partners:

We,

(name of partner 1)

,

(name of partner 2)

,

(name of partner 3)

,

(name of partner 4)

, employees at

,
(exact name of partnership) (CT registration number)

,

hereby elect to:

q q

BE EXCLUDED FROM COVERAGE

under the Workers Compensation Act pursuant to Section 31-275(10) of the Connecticut General Statutes from the provisions of Section 31-275(10) of the Connecticut General Statutes

REVOKE ANY PREVIOUS ELECTION OF EXCLUSION

AFFIRMATIONS
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)

.

Partner 1: Signature

Partner 2: Signature

Partner 3: Signature

Partner 4: Signature