Governor  Dannel P. Malloy

Second Injury Fund

Documents & Forms

Assessment Rates Schedules, Remittance Slips and Statutes

I.   Treasurer's Letter For Fiscal Year 2019
      Treasurer Nappier's Assessment Rate Letter - May 1, 2018

II.   Assessment Rates Schedule
      Assessment Rates Schedule - Revised May 1, 2018

III.  Quartertly Remittance Advice
Two steps are required for submitting the quarterly findings:

1. Complete and submit with payment the Quarterly Remittance Advice - 2nd Quarter 2018


2. Download complete and submit the Quarterly Remittance Template. If you have problems downloading or saving this file call 860-702-3173.

 IV.  Archived Remittance Slips

V.   Paid Loss and Surcharge Base Report

Two steps are required for submitting the yearly Paid Loss and Surcharge Base Report:

1. Complete and submit the 2017 Paid Loss Surcharge Base Report


2. Download, complete and submit one of the following:

a. Insurance Company - Paid Loss Template


b. Self-Insured Company - Paid Loss Template

 VI.  Annual Report to Governor
         Fiscal Year 2018 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

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