State of Connecticut Workers’ Compensation Commission
Coverage Election by Employee who is an Officer of a Corporation or a Member of an LLC _____ DO NOT SEND THIS FORM TO A DISTRICT OFFICE! Send to: WORKERS’ COMPENSATION COMMISSION 21 OAK STREET, 4th FLOOR HARTFORD, CT 06106 Pursuant to C.G.S. Section 31-321, this notice must be served upon the Workers’ Compensation Commission in person OR ................
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