Connecticut acknowledgement of coverage selection form: Fill out & sign online

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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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