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

Form 75 - COVERAGE ELECTION BY SOLE PROPRIETOR. This form is used by sole proprietors in Connecticut to make an election regarding their coverage under the Workers' Compensation Act. Sole proprietors are not automatically covered by the Act, and this form allows them to elect whether to be included for coverage or revoke any previous election of inclusion. The form requires the sole proprietor's information, including their name, address, date of birth, and signature. Additionally, the form requires information about the business or company, such as its name, address, federal employer identification number, and CT registration number. An affirmation on the form states that workers' compensation insurance is required for all covered employees. The completed form should be sent to the Workers' Compensation Commission. Incomplete or illegible forms will be returned unstamped. www.FormsWorkflow.com