Please TYPE or PRINT IN INK
Rev. 4-30-2009
State of Connecticut Workers Compensation Commission
Date filed in District
75
Coverage Election by Sole Proprietor or Single-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
The Sole Proprietor or Single-Member LLC is NOT covered by the Workers Compensation Act, unless coverage is elected through the use of this form.
To the Compensation Commissioner for the
(district number)
Compensation District of Connecticut at
(city of compensation office)
,
the undersigned sole proprietor of a business or member of a single-member LLC hereby elects to:
q q
BE INCLUDED FOR COVERAGE
under the Workers Compensation Act pursuant to Section 31-275 of the Connecticut General Statutes pursuant to the provisions of Section 31-275 of the Connecticut General Statutes
REVOKE ANY PREVIOUS ELECTION OF INCLUSION
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
PRINT Employee Name
Address
City/Town
State
Zip Code
..........................................................................................................................................................
Business / Company Name
Address
City/Town
State
Zip Code
Federal Employer Identification Number
CT Registration Number