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Fill and Sign the Notice of Intention to Be Included Connecticut Form

Fill and Sign the Notice of Intention to Be Included Connecticut Form

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To the compensation Commissioner for the      Compensation District of Connecticut at       be included for coverage under the provisions of Sec. 31-275 of the Connecticut General Statutes. Dated at                                                                               75 (Sole proprietor) STATE OF CONNECTICUT WORKERS' COMPENSATION COMMISSION NOTICE TO COMMISSIONER OF INTENTION TO BE INCLUDED FOR COVERAGE UNDER THE WORKERS' COMPENSATION LAW, OR TO REVOKE PREVIOUS INCLUSION (Please Type or Print in Ink) District # District Office Address The undersigned sole proprietor of a business hereby elects to:[ ] [ ] revoke any previous inclusion for coverage under the provisions of Sec. 31-275 of the Connecticut General Statutes. I fully understand that I am included for coverage under the Workers' Compensation Law only after securing proper insurance coverage by complying with Sec. 31-284 of the Connecticut General Statutes, and that I am eligible for coverage under the law only as long as the insurance policy remains in effect. thi s day of City or Town Name of business/corporation Print name of employee Business street address Employee's social security # Business city, state, zip Employee's street address Federal Employer Identification Number Employee's city, state, zip CT registration Employee's signature NOTE: This notice should be served upon the Commissioner in person or by registered/certified mail. Rev. 1/24/2000

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