Coverage Election By Employee Who Is An Officer Or Member
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Coverage Election By Employee Who Is An Officer Or Member Form. This is a Connecticut form and can be use in Workers Compensation.
Tags: Coverage Election By Employee Who Is An Officer Or Member, 6B, Connecticut Workers Compensation,
AFFIRMATION - Section 31-284 of the Connecticut General Statutes requires that workers222 compensation insurancebe obtained for all covered employees. Dated on this � day of � , � 20 � . (number) � (month) � (year) Employee Signature � Date of Birth (required)Employee Street Address City or Town � State � Zip Code (for WCC use only) 6BPlease TYPE or PRINT IN INKRev. 6-17-2019State of ConnecticutWorkers222 Compensation Commission COVERAGE ELECTION - and to � of (name of employer) � (street address) located in � , � , � : (city or town) � (state) � (zip code) I, � , an Employee of (name of employee)of (exact name of corporation or LLC) � (street address) located in � , � , (city or town) � (state) � (zip code) and also the � of said Corporation or LLC, hereby elect to:BE EXCLUDED under the Workers222 Compensation Act pursuant to Section 31-275 of the Connecticut General Statutes from the provisions of Section 31-275 of the Connecticut General Statutes Coverage Election by Employee who is anDO NOT SEND THIS FORM TO A DISTRICT OFFICE! Send to: � WORKERS222 COMPENSATION COMMISSION � 21 OAK STREET, 4th FLOOR � HARTFORD, CT 06106 Pursuant to C.G.S. Section 31-321, this notice must be servedupon the Workers222 Compensation Commission in person OR. IF YOU WISH TO RECEIVE A DATE-STAMPED COPY OFTHIS FORM, SEND: � 2 COPIES of each forma self-addressed STAMPEDenvelope American LegalNet, Inc. www.FormsWorkFlow.com
