Coverage Election By Sole Proprietor Or Single Member LLC
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Coverage Election By Sole Proprietor Or Single Member LLC Form. This is a Connecticut form and can be use in Workers Compensation.
Tags: Coverage Election By Sole Proprietor Or Single Member LLC, 75, Connecticut Workers Compensation,
(for WCC use only) 75 Coverage Election by Sole ProprietorDO 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.Please TYPE or PRINT IN INKRev. 6-17-2019State of ConnecticutWorkers222 Compensation Commission COVERAGE ELECTION - NOTthe undersigned sole proprietor of a business hereby elects to: under the Workers222 Compensation Act pursuant to Section 31-275 of the Connecticut General Statutes pursuant to the provisions of Section 31-275 of the Connecticut General Statutes AFFIRMATION - Dated on this � day of � , � 20 � . (number) � (month) � (year) Employee Signature � PRINT Employee Name Address � Date of Birth (required) City/Town � State � Zip Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Business / Company Name � Address City/Town � State � Zip Code � 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
