ACORD 172CT Instructions

ACORD 172 CT (4/96) – Workers’ Compensation Commission of Connecticut, Coverage Selection Form for Employees Who are Members of a Partnership

Use this form to notify the Workers’ Compensation Commission of Connecticut that employees who are members of a partnership elect to either be excluded from workers compensation insurance coverage, or to revoke any previous election of exclusion.

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