7C
Proof of Workers’ Compensation Coverage when Applying
for a Building Permit for the General Contractor or Principal
Employer who has chosen to be EXCLUDED from Coverage
Please TYPE or PRINT IN INK
Rev. 3-17-2006
State of Connecticut
Workers’ Compensation Commission
ATTEST
If you are the General Contractor or Principal Employer of a business doing work on the site of the construction project at the above-named property and you
have properly excluded yourself from workers’ compensation coverage by filing one of the appropriate forms listed below with the Workers’ Compensation
Commission, complete this form and, if applicable, sign the Affidavit below in the presence of a Notary Public or a Commissioner of the Superior Court.
FIRST — CHECK ONE (1) BOX:
I am: an Officer of a Corporation a Manager or Member of an LLC a Partner in a Business
THEN — CHECK ONE (1) BOX, provide the appropriate information, and sign the Affidavit below:
I have filed the following certificate with the Workers’ Compensation Commission:
Form 6B (for an Officer of a Corporation, a Manager of an LLC, or a Member of a Multiple-Member LLC)
Form 6B-1 (for a Partner in a Business)
AFFIDAVIT
I hereby swear and attest that I will require proof of workers’ compensation insurance for every contractor,
subcontractor, or other worker before he or she does work on the site of the construction project at the
above-named property in accordance with Section 31-286b of the Workers’ Compensation Act.
Signature of GENERAL CONTRACTOR or PRINCIPAL EMPLOYER Applicant
Name of Business—if applicable
Federal Employer ID# (FEIN)—if applicable
Subscribed and sworn to before me this day of , 200 .
Signature of Notary Public / Commissioner of the Superior Court
APPLICANT FOR BUILDING PERMIT
Name of Applicant for Building Permit
Property located at
in the City / Town of
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signature
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signature
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