Free FORM - Connecticut


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State: Connecticut
Category: Workers Compensation
Author: WCC
Word Count: 210 Words, 1,565 Characters
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http://wcc.state.ct.us/download/acrobat/75.pdf

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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