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Fill and Sign the Coverage Selection Partnership Connecticut Form

Fill and Sign the Coverage Selection Partnership Connecticut Form

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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      at       , and to             that has a total of       I,                         employees at             Dated on this             Social Security #       Social Security #       Social Security #       Social Security #       6B-1 (Members of a Partnership) STATE OF CONNECTICUTWORKERS' COMPENSATION COMMISSION COVERAGE SELECTION FORM FOR EMPLOYEES WHO ARE MEMBERS OF A PARTNERSHIP (Please Type or Print in Ink) Compensation District of Connecticut district # o f City of Compensation Office Name of Partnership I Complete Address of Partnership partners: # of partners I I Name of Partner I Name of Partner 2 I I Name of Partner 3 Name of Partner 4 (Attach additional sheets for names, signatures and social security #s, if there are more than four partners.) Exact Name of Partnership CT Registration Number hereby elect to: [ ] 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 Section 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 Signature of Partner 1 Signature of Partner 2 Signature of Partner 3 Signature of Partner 4 Rev. 1/24/2000

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