Coverage Election By Employee Who Is Officer Of Corporation Manager Of LLC Or Member Of Multiple Member LLC
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Coverage Election By Employee Who Is Officer Of Corporation Manager Of LLC Or Member Of Multiple Member LLC Form. This is a Connecticut form and can be use in Workers Compensation.
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6B
Rev. 4-30-2009
State of Connecticut
Workers Compensation Commission
Date filed in District
Coverage Election by Employee who is an
Officer of a Corporation, Manager of an LLC,
or Member of a Multiple-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
To the Compensation Commissioner for the
Compensation District of Connecticut at
(district number)
and to
(city of compensation office)
of
, Employer:
(name of employer)
I,
(employers city/town)
, an Employee of
(name of employee)
, located at
(exact name of corporation or LLC)
, and also the
(complete address of corporation or LLC)
of said Corporation or LLC,
(office held)
hereby elect to:
q
BE EXCLUDED FROM COVERAGE
q
REVOKE ANY PREVIOUS ELECTION OF EXCLUSION
under the Workers Compensation Act pursuant to Section 31-275 of the Connecticut General Statutes
from the provisions of Section 31-275 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.
Dated on this
day of
(number)
, 20
(month)
.
(year)
Employee Signature
Employee Address
City/Town
State
Zip Code
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