ACORD 173CT Instructions

ACORD 173 CT (4/96) – Worker’s Compensation Commission of Connecticut, Coverage Selection Form for Employee Who is a Sole Proprietor

Use this form to notify the Workers Compensation Commission of Connecticut that a sole proprietor of a business elects to either be included in workers compensation coverage, or to revoke any previous election of inclusion.

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