Coverage Election Forms

  Form 6B, 6B-1 and 75 Directions

_{PDF File:  1 page; Last revised December 15, 2022}
 

Election of Workers' Compensation Coverage for Certain Employees under the Workers' Compensation Act OR Revocation of Previous Election of Such Coverage

Form 6B, 6B-1 and 75 Directions for filing the forms 6B, 6B-1, and 75 (below) used when electing to be covered under the Connecticut Workers’ Compensation Act or when revoking a previous election of such coverage.

  Form 6B

_{PDF File:  1 page; Last revised December 15, 2022}
 

Effective December 15, 2022, Forms 6B can be filed electronically at: https://forms.office.com/g/MPrz0UL2sr.

Coverage Election by Employee who is an Officer of a Corporation or a Manager of an LLC

The Form 6B is to be completed by an Officer of a Corporation or a Manager of a Limited Liability Company (LLC) who wishes to be excluded from workers’ compensation insurance coverage.

It is also used for such an officer or manager to revoke any previous election of exclusion from workers’ compensation coverage.

  Form 6B-1

_{PDF File:  1 page; Last revised December 15, 2022}
 

Coverage Election by Employees who are Members of a Partnership

The Form 6B-1 is to be completed by all members of a partnership who wish to be excluded from workers’ compensation insurance coverage.

It is also used for such members to revoke any previous election of exclusion from workers’ compensation coverage.

  Form 75

_{PDF File:  1 page; Last revised December 15, 2022}
 

Coverage Election by Sole Proprietor

The Form 75 is to be completed by a Sole Proprietor of a business who wishes to be included for workers’ compensation insurance coverage.

It is also used for such a sole proprietor to revoke any previous election of inclusion for workers’ compensation coverage.

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