INSTRUCTIONS: CONNECTICUT ANNUAL PEO CERTIFICATION

In Connecticut, companies which outsource human resources and health insurance responsibilities to a professional employer organization (PEO) are required to file an annual certification regarding this. The document discussed in this article can be obtained from the website maintained by the government of the state of Connecticut.

Connecticut Annual PEO Certification Step 1: On the first blank line, enter the name of the company. A separate form must be submitted for each company name.

Connecticut Annual PEO Certification Step 2: On the second blank line, enter the company address.

Connecticut Annual PEO Certification Step 3: On the third blank line, enter the NAIC number of the company.

Connecticut Annual PEO Certification Step 4: The next section requires you to list all professional employer organizations for which the company is providing a large group health insurance product. Where indicated, enter the name of each professional employer organization.

Connecticut Annual PEO Certification Step 5: For each professional employer organization, indicate with a check mark whether it is fully integrated.

Connecticut Annual PEO Certification Step 6: For each professional employer organization, indicate with a check mark whether they have submitted certification with the application for coverage which they have achieved and will continue to maintain throughout the term of the underlying insurance policy fully integrated co-employer status with each participant enrolled under the contract.

Connecticut Annual PEO Certification Step 7: The next section requires you to list all professional employer organizations for which the company is providing large group self-funded administration. Enter the name of all such organizations where indicated.

Connecticut Annual PEO Certification Step 8: Indicate whether every professional employer organization listed here is fully integrated with a check mark where indicated.

Connecticut Annual PEO Certification Step 9: Indicate with a check mark whether every professional employer organization listed here has submitted certification with the application for coverage that they have achieved and will continue to maintain throughout the term of the underlying insurance policy fully integrated co-employer status with each participant enrolled under the contract.

Connecticut Annual PEO Certification Step 10: On the second page, an officer of the organization should print their name on the first blank line, enter their title on the second blank line, and enter the name of their company or organization on the third blank line. Sign and date the form where indicated.