Connecticut > Workers Compensation
Coverage Election By Employees Who Are Members Of Partnership 6B-1 - Connecticut
| Coverage Election By Employees Who Are Members Of Partnership 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 Employees who are Members of a Partnership 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. If there are more than four partners, attach additional sheets for names, signatures, and dates of birth. 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-1 (for WCC use only) COVERAGE ELECTION To the Workers Compensation Commission, 21 Oak Street, 4th Floor, Hartford, Connecticut 06106 and to (name of partnership) of (complete address of partnership) having a total of (number) partners: We, (name of partner 1) , (name of partner 2) , (name of partner 3) , (name of partner 4) , employees at , (exact name of partnership) (CT registration number) , hereby elect to: q q BE EXCLUDED FROM COVERAGE under the Workers Compensation Act pursuant to Section 31-275(10) of the Connecticut General Statutes from the provisions of Section 31-275(10) of the Connecticut General Statutes REVOKE ANY PREVIOUS ELECTION OF EXCLUSION AFFIRMATIONS 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) . Partner 1: Signature Partner 2: Signature Partner 3: Signature Partner 4: Signature Date of Birth (required) Date of Birth (required) Date of Birth (required) Date of Birth (required) American LegalNet, Inc. www.FormsWorkFlow.com
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