Documents & Forms

Important Postal Service address directive: Use - Office of the State Treasurer, 165 Capitol Ave., Hartford, CT 06106 - Do not use 55 Elm St.

I. Treasurer's Letter For Fiscal Year 2022

Treasurer Wooden's Assessment Rate Letter - May 1, 2022

II. Assessment Rates Schedule
Assessment Rates Schedule - Revised May 1, 2022

III. Quarterly Remittance Advice*

Two steps are required for submitting the quarterly findings:
1. Complete and submit payment of the Quarterly Remittance Advice - 1st Quarter 2022 [Updated 3/15/22]

and

2. Download complete and submit the Quarterly Remittance Template [Updated 12/2020]

IV. Archived Remittance Slips

V. Paid Loss and Surcharge Base Report

Two steps are required for submitting the yearly Paid Loss and Surcharge Base Report:

1. Complete and submit the 2021 Paid Loss Surcharge Base Report [Updated 12/28/21]

and

2. Download, complete and submit one of the following:

a. Insurance Company - Paid Loss Template

or

b. Self-Insured Company - Paid Loss Template

VI. Annual Report to Governor
Fiscal Year 2021 Annual Report of the Financial Condition of the Second Injury Fund

VII. Connecticut Second Injury Fund Statutes and Regulations
Statutes on Assessments for policies dated 7/1/06 and forward
Regulations on Assessments for policies dated 6/30/06 and prior

* Note: Penalty on Late Assessment Payments, as of 2010: Any employer or any insurance company acting as collection agent for the custodian of the Second Injury Fund who fails to pay in accordance with such regulations shall pay a penalty to the State Treasurer of fifteen per cent on the unpaid assessment or surcharge or fifty dollars, whichever is greater. Act Concerning Interest Penalties on Late Payment of Assessments to the Second Injury Fund

The Office of Treasurer Shawn T. Wooden