WORKERS' COMPENSATION COVERAGE QUESTIONNAIRE TO: State of Connecticut, Department of Banking Securities and Business Investments Division 260 Constitution Plaza Hartford, CT 06103-1800 FROM: (Applicant for Registration) (Street) (City/Town, State, Zip Code) TYPE OF REGISTRATION (Check): ( ) Broker-Dealer ( ) Investment Adviser Section 31-286a(b) of the Connecticut General Statutes provides that “[o]n and after October 1, 1986, no state department, board or agency may renew a license or permit to operate a business in this state unless the applicant first presents sufficient evidence of current compliance with the workers' compensation requirements of section 31-284.” Subsection (d) of Section 31-286a states that “[f]or purposes of this section, ‘sufficient evidence’ means (1) a certificate of self-insurance issued by a workers’ compensation commissioner pursuant to Section 31-284, or (2) a certificate of compliance issued by the insurance commissioner pursuant to Section 31-286, or (3) a certificate of insurance issued by any stock or mutual insurance company or mutual association authorized to write workers’ compensation insurance in this state or its agent.” If you have questions about how Section 31-286a or Section 31-284 of the Connecticut General Statutes applies to you, please direct them to your attorney or to the Workers’ Compensation Commission at (860) 493-1500 rather than to the Department of Banking.*** *** CHECK ONLY ONE OF THE FOLLOWING BOXES: ( ) The applicant will not be operating a business in Connecticut within the meaning of Section 31-286a(b) of the Connecticut General Statutes and is not subject to Section 31-284 of the Connecticut General Statutes. ( ) The applicant will be operating a business in Connecticut within the meaning of Section 31-286a(b) of the Connecticut General Statutes and has attached a photocopy of the certificate required by that section. Print Name of Person Signing Here: Rev. 01/2001 Title: Date: American LegalNet, Inc. www.USCourtForms.com