State of Connecticut Workers' Compensation Commission, John A. Mastropietro, Chairman
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Forms 6B, 6B-1 and 75 Revised

July 17, 2013

The Commission’s Forms 6B, 6B-1 and 75 have just been revised, with a revision date of July 15, 2013. Please use these newest revisions of the Forms 6B, 6B-1 and 75, which can be obtained below or from our Online Forms page.

The Commission has also created a set of Directions available for those classes of persons who — under the Workers’ Compensation Act — wish to be excluded from workers’ compensation insurance coverage or to revoke any previous election of exclusion from workers’ compensation coverage.

In Addition to the newly-revised FORMS 6B, 6B-1 and 75, THERE IS ALSO A NEW PROCEDURE FOR OBTAINING A DATE-STAMPED COPY OF A FORM 6B, 6B-1 AND 75. If you file a Form 6B, 6B-1 or 75 and you wish to receive a date-stamped copy of the form, then when you file your Form 6B, 6B-1 or 75 you will ALSO need to include:

 

Form 6B, 6B-1 and 75 Directions (PDF File: 1 page; 59K; Last revised July 15, 2013)

Form 6B, 6B-1 and 75 Directions

(PDF File: 1 page; 59K; Last revised July 15, 2013)

Form 6B, 6B-1 and 75 Directions “ELECTION OF WORKERS’ COMPENSATION COVERAGE FOR CERTAIN EMPLOYEES UNDER THE WORKERS’ COMPENSATION ACT OR REVOCATION OF PREVIOUS ELECTION OF SUCH COVERAGE” provides directions for filing the 6B, 6B-1, and 75 forms (below) used by various persons when electing to be covered under the Connecticut Workers’ Compensation Act or when revoking a previous election of such coverage.

 

Form 6B (PDF File: 1 page; 75K; Last revised July 15, 2013)

Form 6B

(PDF File: 1 page; 75K; Last revised July 15, 2013)

The Form 6B “COVERAGE ELECTION BY EMPLOYEE WHO IS AN OFFICER OF A CORPORATION, MANAGER OF AN LLC, OR MEMBER OF A MULTIPLE-MEMBER LLC” is to be completed by an Officer of a Corporation, a Manager of a Limited Liability Company (LLC), or a Member of a Multiple-Member Limited Liability Company (LLC) who wishes to be excluded from workers’ compensation insurance coverage. It is also used for such an officer, manager, or member to revoke any previous election of exclusion from workers’ compensation coverage.

 

Form 6B-1 (PDF File: 1 page; 75K; Last revised July 15, 2013)

Form 6B-1

(PDF File: 1 page; 75K; Last revised July 15, 2013)

The Form 6B-1 “COVERAGE ELECTION BY EMPLOYEES WHO ARE MEMBERS OF A PARTNERSHIP” is to be completed by all members of a partnership who wish to be excluded from workers’ compensation insurance coverage. It is also used for such members to revoke any previous election of exclusion from workers’ compensation coverage.

 

Form 75 (PDF File: 1 page; 77K; Last revised July 15, 2013)

Form 75

(PDF File: 1 page; 77K; Last revised July 15, 2013)

The Form 75 “COVERAGE ELECTION BY SOLE PROPRIETOR OR SINGLE-MEMBER LLC” is to be completed by a Sole Proprietor of a business or a Single-Member Limited Liability Company (LLC) who wishes to be included for workers’ compensation insurance coverage. It is also used for such a sole proprietor or member to revoke any previous election of inclusion for workers’ compensation coverage.

Forms are available on this site in Adobe PDF format and require the use of Adobe’s free Adobe Reader. If you need to obtain the free Adobe Reader, follow the link below to Adobe Software’s website, download and install the Reader on your computer, then return to this page to access the newly-revised Forms 6B, 6B-1 and 75, as well as the Form 6B, 6B-1 and 75 Directions.

Click here for the FREE Adobe Reader from Adobe Software.

Click here for the FREE Adobe Reader from Adobe Software.

Workers’ Compensation Commission

Page last revised: July 17, 2013

Page URL: http://wcc.state.ct.us/news/new-599.htm

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State of Connecticut Workers' Compensation Commission, John A. Mastropietro, Chairman
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