Governor  Dannel P. Malloy
 

Second Injury Fund

Documents & Forms

Assessment Rates Schedules, Remittance Slips and Statutes

I.  Treasurer’s Letter For Fiscal Year 2017

Treasurer Nappier’s Assessment Rate Letter – May 1, 2016

II.  Assessment Rates Schedule

Assessment Rates Schedule - Revised 9/29/16

III. Remittance Slips for Calendar Year 2016  #

4th QTR 2016
3rd QTR 2016
2nd QTR 2016
1st QTR 2016

NOTE: This template for Second Injury Fund Surcharge Assessment must be downloaded quarterly and completed when Company submits the applicable and equivalent remittance slip.  View a completed sample template for illustrative purposes only.

IV. Archived Remittance Slips

V.  Paid Loss Reporting Forms:

2016 Paid Loss And Surcharge Base Report

2015 Paid Loss And Surcharge Base Report

NOTE: This template for Second Injury Fund Paid Loss Assessment Report must be downloaded anually and completed when Company submits the applicable and equivalent paid loss and surcharge base form.  View a completed sample template for illustrative purposes only.

VI.
Annual Report to Governor

Fiscal Year 2016  Annual Report of the Financial Condition of the Second Injury Fund

VII. Connecticut Second Injury Fund Statutes and Regulations

Statutes on Assessments for policies dated 7/1/06 and forward

Regulations on Assessments for policies dated 6/30/06 and prior

# Note: Penalty on Late Assessment Payments, as of 2010: Any employer or any insurance company acting as collection agent for the custodian of the Second Injury Fund who fails to pay in accordance with such regulations shall pay a penalty to the State Treasurer of fifteen per cent on the unpaid assessment or surcharge or fifty dollars, whichever is greater. http://www.cga.ct.gov/2010/ACT/PA/2010PA-00011-R00HB-05201-PA.htm