ACORD 171CT Instructions


ACORD 171 CT (4/96) – Workers’ Compensation Commission of Connecticut Coverage Selection Form for Employee Who is an Officer of the Corporation

Use this form to notify the Workers’ Compensation Commission of Connecticut that an employee who is an officer of a corporation elects to either be excluded from workers compensation coverage, or to revoke any previous election of exclusion.

The notice becomes effective only after served upon the employer and the District Compensation Commissioner by personal delivery, registered or certified mail.