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Connecticut acknowledgement of coverage selection form

Coverage Selection Form - Connecticut 2026

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The document is a Workers' Compensation Coverage Selection Form for employees who are officers of a corporation or managers of an LLC in Connecticut. It allows the employee to elect either to be excluded from workers' compensation coverage or to revoke a previous exclusion. The form requires personal information about the employee and the corporation or LLC, and must be submitted to the Compensation Commissioner.

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Click ‘Get Form’ to open the Coverage Selection Form in the editor.
Begin by entering the Compensation District of Connecticut where your employer is located. This information is crucial for proper processing.
Fill in the name of your employer and their complete address. Ensure accuracy to avoid any delays.
Next, provide your name as the employee and your Social Security number. This personal identification is necessary for verification purposes.
Indicate your position within the corporation or LLC by filling in the 'Office Held' section.
Choose whether you wish to be excluded from coverage under Workers' Compensation law by checking the appropriate box. Alternatively, if you are revoking a previous exclusion, select that option.
Finally, date and sign the form, providing your street address and city/state/zip code to complete the submission process.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is a coverage form?

In insurance, a coverage form refers to the specific document or contract that outlines the terms, conditions, and extent of coverage provided by an insurance policy.

What is a coverage package?

More than two types of insurance cover combined into a single contract; also called a multi-line policy. A package policy in insurance is a type of insurance policy that combines multiple coverages into a single, comprehensive plan.

What is a coverage selection form?

Coverage selection form means part of a written notice required to be given to insureds and prospective insureds for automobile insurance, pursuant to N.J.S.A. 39:6A-23, which provides information required by the Commissioner pursuant to N.J.A.C.

What coverage is mandatory to drive a vehicle in CT?

Protecting Your Rights: By signing the rejection form, you acknowledge that youve been offered UM/UIM coverage and have chosen to decline it. This document can be important in case youre involved in an accident with an uninsured or underinsured driver.

What is acknowledgment of coverage selection or rejection?

California law does not require you to carry uninsured motorist (UM) or underinsured motorist (UIM) coverageso, legally, you dont need either one. However, UM/UIM is an important and commonsense coverage to carry.

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What is basic coverage?

Basic coverage is a Named Peril policy, which means that for a loss to be covered, the peril must be listed by name on the declarations page. In addition, you carry the burden of proving that a loss was caused by an included peril. Basic Form is typically the cheapest of the three coverage options.

What are forms in insurance?

A proposal form is a formal application document that an individual fills out when applying for an insurance policy. This form is used by insurance companies to gather detailed information about the prospective policyholder.

Coverage Selection Form - Connecticut 2026

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