Governor  Dannel P. Malloy
 

Second Injury Fund

Documents & Forms

Assessment Rates Schedules, Remittance Slips and Statutes

I.   Treasurer’s Letter For Fiscal Year 2018
      Treasurer Nappier’s Assessment Rate Letter – May 1, 2017

II.   Assessment Rates Schedule
      Assessment Rates Schedule - Revised 5/01/2017

III.  Remittance Slips for Calendar Year 2017
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        1st QTR 2017
        2nd QTR 2017     
      
  3rd QTR 2017

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 2017  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

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  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. Act Concerning Interest Pennalties on Late Payment of Assesments to the Second Injury Fund