7a - Proof Of Worker'S Compensation Coverage - State Of Connecticut Workers' Compensation Commission

Download a blank fillable 7a - Proof Of Worker'S Compensation Coverage - State Of Connecticut Workers' Compensation Commission in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete 7a - Proof Of Worker'S Compensation Coverage - State Of Connecticut Workers' Compensation Commission with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

State of Connecticut

Workers’ Compensation Commission

Please TYPE or PRINT IN INK

Proof of Workers’ Compensation Coverage when Applying

for a Building Permit for the Sole Proprietor or Property Owner

who WILL NOT act as General Contractor or Principal Employer

Applicant for Building Permit

Name of Applicant for Building Permit

Property located at

in the City / Town of

Attest

If you are the owner of the above-named property or the sole proprietor of a business doing work on the site of the construction project at the above-named

property and you WILL NOT act as the general contractor or principal employer, you are not required to have workers’ compensation insurance coverage.

CHECK ONE (1) BOX ONLY and complete the following:

I am the OWNER

of the above-named property. I WILL NOT act as the general contractor or principal employer.

Signature of OWNER Applicant

I am the SOLE PROPRIETOR

of a business doing work at the above-named property. I WILL NOT act as the general contractor or principal employer.

Name of Business

Federal Employer ID# (FEIN)

Signature of SOLE PROPRIETOR Applicant