Coverage Election By Sole Proprietor Or Single Member LLC {75} | Pdf Fpdf Docx | Connecticut

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Coverage Election By Sole Proprietor Or Single Member LLC {75} | Pdf Fpdf Docx | Connecticut

Coverage Election By Sole Proprietor Or Single Member LLC {75}

This is a Connecticut form that can be used for Workers Compensation.

Alternate TextLast updated: 7/9/2019

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Description

(for WCC use only) 75 Coverage Election by Sole ProprietorDO NOT SEND THIS FORM TO A DISTRICT OFFICE! Send to: þ WORKERS222 COMPENSATION COMMISSION þ 21 OAK STREET, 4th FLOOR þ HARTFORD, CT 06106 Pursuant to C.G.S. Section 31-321, this notice must be servedupon the Workers222 Compensation Commission in person OR.Please TYPE or PRINT IN INKRev. 6-17-2019State of ConnecticutWorkers222 Compensation Commission COVERAGE ELECTION - NOTthe undersigned sole proprietor of a business hereby elects to: under the Workers222 Compensation Act pursuant to Section 31-275 of the Connecticut General Statutes pursuant to the provisions of Section 31-275 of the Connecticut General Statutes AFFIRMATION - Dated on this þ day of þ , þ 20 þ . (number) þ (month) þ (year) Employee Signature þ PRINT Employee Name Address þ Date of Birth (required) City/Town þ State þ Zip Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Business / Company Name þ Address City/Town þ State þ Zip Code þ IF YOU WISH TO RECEIVE A DATE-STAMPED COPY OFTHIS FORM, SEND: þ 2 COPIES of each forma self-addressed STAMPEDenvelope American LegalNet, Inc. www.FormsWorkFlow.com

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