State of Connecticut Workers' Compensation Commission
Please TYPE or PRINT IN INK
Proof of Workers' Compensation Coverage when Applying for a Building Permit for the General Contractor or Principal Employer who has chosen to be EXCLUDED from Coverage
APPLICANT FOR BUILDING PERMIT
Name of Applicant for Building Permit Property located at in the City / Town of
If you are the General Contractor or Principal Employer of a business doing work on the site of the construction project at the above-named property and you have properly excluded yourself from workers' compensation coverage by filing one of the appropriate forms listed below with the Workers' Compensation Commission, complete this form and, if applicable, sign the Affidavit below in the presence of a Notary Public or a Commissioner of the Superior Court.
FIRST -- CHECK ONE (1) BOX:
an Officer of a Corporation
a Manager or Member of an LLC
a Partner in a Business
THEN -- CHECK ONE (1) BOX, provide the appropriate information, and sign the Affidavit below:
I have filed the following certificate with the Workers' Compensation Commission: Form 6B (for an Officer of a Corporation, a Manager of an LLC, or a Member of a Multiple-Member LLC) Form 6B-1 (for a Partner in a Business) AFFIDAVIT
I hereby swear and attest that I will require proof of workers' compensation insurance for every contractor, subcontractor, or other worker before he or she does work on the site of the construction project at the above-named property in accordance with Section 31-286b of the Workers' Compensation Act.
Signature of GENERAL CONTRACTOR or PRINCIPAL EMPLOYER Applicant Name of Business--if applicable Federal Employer ID# (FEIN)--if applicable
Subscribed and sworn to before me this
Signature of Notary Public / Commissioner of the Superior Court