Please TYPE or PRINT IN INK Rev. 7-15-2015 State of Connecticut Workers' Compensation Commission 6B-1 Date filed with WCC Coverage Election by Employees who are Members of a Partnership DO NOT SEND THIS FORM TO A DISTRICT OFFICE! Send to: WORKERS' COMPENSATION COMMISSION 21 OAK STREET, 4th FLOOR HARTFORD, CT 06106 ________________________________________________________________ IF YOU WISH TO RECEIVE A DATE-STAMPED COPY OF THIS FORM, SEND: · 2 COPIES of each form · a self-addressed STAMPED envelope (for WCC use only) Pursuant to C.G.S. Section 31-321, this notice must be served upon the Workers' Compensation Commission in person OR by registered or certified mail. 4444444444444 Incomplete and/or illegible forms will be returned unstamped. 3333333333333 COVERAGE ELECTION - To the Workers' Compensation Commission, 21 Oak Street, 4th Floor, Hartford, Connecticut 06106 and to (name of partnership) of (street address) located in We, (city or town) , , , (state) , (zip code) and having a total of , , employees at (number) partners: (name of partner 1) (name of partner 2) (name of partner 3) (name of partner 4) , (exact name of partnership) (CT registration number) , hereby elect to: BE EXCLUDED FROM COVERAGE under the Workers' Compensation Act pursuant to Section 31-275(10) of the Connecticut General Statutes REVOKE ANY PREVIOUS ELECTION OF EXCLUSION from the provisions of Section 31-275(10) of the Connecticut General Statutes AFFIRMATION - Section 31-284 of the Connecticut General Statutes requires that workers' compensation insurance be obtained for all covered employees. day of (number) (month) Dated on this , 20 (year) . Partner 1: Signature Date of Birth (required) Partner 2: Signature Date of Birth (required) Partner 3: Signature Date of Birth (required) Partner 4: Signature Date of Birth (required) Please be advised that the Workers' Compensation Commission accepts the coverage election form 6B-1 for filing purposes ONLY. The filer of this form is solely responsible for the accuracy of the information contained herein. American LegalNet, Inc. www.FormsWorkFlow.com