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How to use or fill out Health and Welfare Fee (Childhood Vaccinations) Assessment Request
- Click ‘Get Form’ to open it in the editor.
- Begin by selecting your filing status under 'FILLING AS'. Choose between Insurer, Exempt Insurer, or TPA. If you select 'Exempt Insurer', provide a brief explanation in the designated field.
- In the 'REPORTING ENTITY' section, fill in your entity name, street address, city, state, zip code, contact person’s name, phone number, and email address. Ensure that the email provided is suitable for receiving invoices.
- Next, report the total number of insured or enrolled lives in Connecticut as of May 1st, 2021. Make sure this number reflects only those covered under specified insurance types. If there are none, indicate 'NONE'.
- Complete the 'CERTIFICATION' section by signing and printing your name and title. Ensure that you are authorized to certify this report on behalf of your company.
- Finally, submit your completed form electronically via email to cid.vax@ct.gov or mail it to the Connecticut Insurance Department at the provided address.
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