Coverage election
Employer Safety and Health Committee Package
Notice to Employees
Self- insurance and managed care plans
Where can employers find forms and safety information?
The Connecticut Workers’ Compensation Commission recommends you use these forms to make sure your paperwork is:
- Up to date
- Correct
- Follow the State’s laws
Most forms are PDFs you can fill out online, print, and save. Others, including Form 6B, you can send electronically.
Health care providers often use the forms below. You’ll find fee schedules with rates and rules and guidelines for them. Form 42, to describe any loss of ability.
Coverage election
You can send a few forms electronically, thanks to our Electronic Form Submission Service. This includes Form 6B, and eventually others. You can send the form here:
6B, 6B-1, and 75 directions: Election of Workers’ Compensation Coverage for Certain Employees under the Workers’ Compensation Act OR Revocation of Previous Election of Such Coverage (PDF) - The directions form explains how to fill out and send Forms 6B, 6B-1, and 75 to make or change coverage choices.
Form 6B: Coverage Election by Employee Who is an Officer of a Corporation or a Member of an LLC (PDF) - Lets a company officer or LLC manager say they don’t want workers’ comp coverage or take back that choice.
Form 6B-1: Coverage Election by Employees who are Members of a Partnership (PDF) - Lets partners in a business say they don’t want workers’ comp coverage or take back that choice.
Form 75: Coverage Election by Sole Proprietor (PDF) - Lets a sole business owner choose to have workers’ comp coverage or take back that choice.
Learn which forms to send with our Electronic Form Submission Service
Use GovQA to send forms, request important documents, verify coverage, and more
Employer Safety and Health Committee Package
Download the Safety and Health Packet (PDF).
It also contains an Inspection form and instructions. Read more about how to keep your workplace safe.
Safety Program Officers (SPOs) from the Workers' Compensation Commission (WCC) visit Connecticut workplaces. They do the following:
- Check that employers follow new rules about safety and health committees
- Return within 30 days of the first visit
- During the second visit, check the safety committee and walk through workplace
Have these items ready:
- A completed inspection form (included in this packet)
- Meeting notes from one safety committee meeting
- A posted list of committee members and their departments
Notice to Employees
Notice to Employees (PDF) - Fill out and put up where workers can easily see it at every job site in Connecticut. For more information, refer to Memorandum No. 2017-08.
Learn how to submit Notice to Employees electronically
Use GovQA to send forms, request important documents, verify coverage, and more
For questions, contact the Safety and Health Services at the Office of the Chairperson in Hartford at 860-493-1500.
Self-insurance and managed care plans
Learn about and get contact information for the self-insurance and managed care plan applications. It does the following:
- Reviews and approves applications from employers to self-insure workers' comp liabilities
- Reviews and approves new Managed Care Plan applications
- Also reviews and approves employer applications for existing Managed Care Plans
- Download the Employer Medical Care Plans Information Packet (PDF)
- Download the Employer Self-Insurance Information Packet (PDF)
View latest lists of self-insureds and managed care plans
Contact:
Managed Care Plan contact
Deb Prendergast, License and Applications Analyst
Phone: 860-493-1555
Self-Insurance contact
Cher Donnelly, License and Applications Supervisor
Phone: 860-493-1562
Division contact
Terri Miro, Administrative and Managed Care Program Manager
Phone: 860-493-1500
Self-Insurance & Managed Care Plans
Workers' Compensation Commission
Capitol Place, 4th Floor
21 Oak Street
Hartford, CT 06106
Use GovQA to send forms, request important documents, verify coverage, and more