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Fill and Sign the Coverage Selection Form Connecticut

Fill and Sign the Coverage Selection Form Connecticut

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Open the document and fill out all its fields.
Apply your legally-binding eSignature.
Save and invite other recipients to sign it.

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To the Compensation Commissioner for the           , and to             I,                               Dated on this             Signature of Employee       Employee Social Security #       Employee Street Address       City, State Zip       6B (Officer of Corporation) (Manager of LLC) STATE OF CONNECTICUT WORKERS' COMPENSATION COMMISSION COVERAGE SELECTION FORM FOR EMPLOYEE WHO IS AN OFFICER OF A CORPORATION OR A MANAGER OF A LLC (Please Type or Print in Ink) Compensation District of Connecticut at District # of City of Compensation Office Name of Employer , Employer: Employer's Town I an Employee at Name of Employee Social Security No. located at Exact Name of Corporation or LLC , who am also the Complete Address of Corporation or LLC , of said Corporation or LLC, hereby elect to: Office Held [ ] be excluded from coverage under the Workers' Compensation law under provisions of Section 31-275 of the Connecticut General Statutes. [ ] revoke any previous election of exclusion from the provisions of Sec. 31-275 of the Connecticut General Statutes. Note: This notice will not be effective until served upon the Commissioner and the Employer by personal delivery, or registered/certified mail. AFFIRMATION day of Rev. 1/24/2000

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