Workers' Compensation Coverage Questionnaire Form - 2001
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1WORKERS’ COMPENSATION COVERAGE QUESTIONNAIRE
TO:
State of Connecticut, Department of Banking
Securities and Business Investments Division
260 Constitution Plaza
Hartford, CT 06l03-1800
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 license or permit
to operate a business in this state unless the applicant first presents sufficient
evidence of current compliance with the workers’ compensation requirements of
section 31-284."
Subsection (d) of Section 3l-286a states that "[f]or purposes of this section, ’sufficient
evidence’ means (1) a certificate of self-insurance issued by a workers’ compensation
commissioner pursuant to Section 3l-284, or (2) a certificate of compliance issued by
the insurance commissioner pursuant to Section 3l-286, or (3) a certificate of
insurance issued by any stock or mutual insurance company or mutual association
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 than 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 3l-286a(b) of the Connecticut General Statutes and is not
subject to Section 3l-284 of the Connecticut General Statutes.
(__)
The applicant will be operating a business in Connecticut within the meaning
of Section 3l-286a(b) of the Connecticut General Statutes and has attached a
photocopy of the certificate required by that section.
_________________________________
Print Name of Person Signing Here:
Title:
Date:
Rev. 01/2001
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