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.
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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 þ day of þ , þ 20 þ . (number) þ (month) þ (year) Employee Signature þ Date of Birth (required)Employee Street Address City or Town þ State þ Zip Code (for WCC use only) 6BPlease TYPE or PRINT IN INKRev. 6-17-2019State of ConnecticutWorkers222 Compensation Commission COVERAGE ELECTION - and to þ of (name of employer) þ (street address) located in þ , þ , þ : (city or town) þ (state) þ (zip code) I, þ , an Employee of (name of employee)of (exact name of corporation or LLC) þ (street address) located in þ , þ , (city or town) þ (state) þ (zip code) and also the þ 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: þ WORKERS222 COMPENSATION COMMISSION þ 21 OAK STREET, 4th FLOOR þ 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: þ 2 COPIES of each forma self-addressed STAMPEDenvelope American LegalNet, Inc. www.FormsWorkFlow.com
