Connecticut > Workers Compensation
Coverage Election By Employee Who Is Officer Of Corporation Manager Of LLC Or Member Of Multiple Member LLC 6B - Connecticut
| 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 used in Workers Compensation . |
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Please TYPE or PRINT IN INK Rev. 1-4-2012 State of Connecticut Workers Compensation Commission 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 Workers Compensation Commission in person or by registered or certified mail. Do NOT file this form at a District Office. Send to: WORKERS COMPENSATION COMMISSION 21 OAK STREET, 4th FLOOR HARTFORD, CT 06106 Date filed with WCC 6B (for WCC use only) COVERAGE ELECTION To the Workers Compensation Commission, 21 Oak Street, 4th Floor, Hartford, Connecticut 06106 and to (name of employer) of (employers city/town) , Employer: I, (name of employee) , an Employee of (exact name of corporation or LLC) , located at (complete address of corporation or LLC) , and also the of said Corporation or LLC, (office held) hereby elect to: q q BE EXCLUDED FROM COVERAGE 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 REVOKE ANY PREVIOUS ELECTION OF EXCLUSION AFFIRMATION Section 31-284 of the Connecticut General Statutes requires that workers compensation insurance be obtained for all covered employees. Dated on this (number) day of (month) , 20 (year) . Employee Signature Employee Address City/Town Date of Birth (required) State Zip Code American LegalNet, Inc. www.FormsWorkFlow.com
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