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Get CT Workers' Compensation Coverage Affidavit 2010-2022

6-216, Section 4, effective June 4, 1996 and as Permittee on the project listed below I hereby choose the following option to verify compliance with the above stated Connecticut Workers' Compensation Laws (Select ONLY one): PROJECT IDENTIFICATION: PROPERTY OWNER(S) __________________________________________________________________________ STREET ADDRESS _____________________________________________________________________________ APT./UNIT NO. ____________ SECTION OF CITY__________________ CT __.

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