Workers Compensation Coverage Questionnaire {WCCQ}

WORKERS COMPENSATION COVERAGE QUESTIONNAIRE TO: State of Connecticut, Department of Banking Securities and Business Investments Division 260 Constitution Plaza Hartford, CT 06103-1800 FROM: (Applicant for Registration) (Street) (City/Town, State, Zip Code) TYPE OF REGISTRATION (Check): ( ) Broker-Dealer ( ) Investment Adviser Section 31-286a(b) of the Connecticut General Statutes provides that [o]n and after October 1, 1986, no state department, board or agency may renew a licens e or permit to operate a business in this state unless the applicant first presents sufficient evidence of current compliance with the workers compensation requiremen ts of section 31-284. Subsection (d) of Section 31-286a states that [f]or purposes of th is section, sufficient evidence means (1) a certificate of self-insurance issued by a wor kers compensation commissioner pursuant to Section 31-284, or (2) a certificate of compl iance issued by the insurance commissioner pursuant to Section 31-286, or (3) a certif icate of insurance issued by any stock or mutual insurance company or mutual asso ciation authorized to write workers compensation insurance in this state or its agent. *** If you have questions about how Section 31-286a or Section 31-284 of the Connecticut General Statutes applies to you, please direct them to your attorney or to the Workers Compensation Commission at (860) 493-1500 rather th an to the Department of Banking.*** CHECK ONLY ONE OF THE FOLLOWING BOXES: ( ) The applicant will not be operating a business in Connecticut within the meaning of Section 31-286a(b) of the Connecticut General Statutes and is not subject to Section 31-284 of the Connecticut General Statutes. ( ) The applicant will be operating a business in Connecticut within the mea ning of Section 31-286a(b) of the Connecticut General Statutes and has atta ched a photocopy of the certificate required by that section. Print Name of Person Signing Here: Title: Date: Rev. 01/2001 American LegalNet, Inc. www.USCourtForms.com