State of Connecticut Workers' Compensation Commission, John A. Mastropietro, Chairman
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FORMS

Authorization for Release of Medical Records (PDF File: 1 page; 28K; Last revised November 23, 2009)

Authorization for Release of Medical Records

(PDF File: 1 page; 28K; Last revised November 23, 2009)

The Form “AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS” provided here may be used by any hospital or provider for the purpose of administering a Connecticut workers’ compensation claim for benefits.

Commutation and What It Means (PDF File: 1 page; 10K; Last revised June 16, 2006)

Commutation and What It Means

(PDF File: 1 page; 10K; Last revised June 16, 2006)

The Form “COMMUTATION AND WHAT IT MEANS” provided here explains what a commutation is, and is to be initialed and then signed by a claimant who wishes to receive a commutation of compensation benefits pursuant to Section 31-302 of the Workers’ Compensation Act.

Employee Medical & Work Status Form (PDF File: 1 page; 328K; Last revised September 26, 2011)

Employee Medical & Work Status Form

(PDF File: 1 page; 328K; Last revised September 26, 2011)

The "EMPLOYEE MEDICAL & WORK STATUS FORM" provided here may be used by a physician to report an injured employee’s medical progress and work status to a payor requesting such information. A copy of the completed form must also be provided to the injured employee.

[NOTE: Also see the Payor and Medical Provider Guidelines to Improve the Coordination of Medical Services publication which describes the purpose and proper use of this form.]

Employer’s First Report of Occupational Injury or Illness (PDF File: 1 page; 85K; Last revised July 13, 2009)

Employer’s First Report of Occupational Injury or Illness

(PDF File: 1 page; 85K; Last revised July 13, 2009)

The Form “EMPLOYER’S FIRST REPORT OF OCCUPATIONAL INJURY OR ILLNESS” is to be completed by an employer or its workers’ compensation insurance carrier to notify the Workers’ Compensation Commission of occupational injuries or illnesses that result in incapacity for one day or more. Unlike many Commission forms, the Employer’s First Report Form must be sent directly to the Commission Chairman’s Office in Hartford. For more information, see Section 31-316 of the Workers’ Compensation Act.

Employer Medical Care Plan Application Package (PDF File: 23 pages; 1.1MB; Last revised April 1, 2014)

Employer Medical Care Plan Application Package

(PDF File: 23 pages; 1.1MB; Last revised April 1, 2014)

Information package for employers wishing to apply for approval to provide medical care and treatment for their injured employees by means of a medical care plan under the Workers’ Compensation Act, along with the required forms and documents.

Employer Safety and Health Committee Information Package (PDF File: 5 pages; 37K; Last revised March 25, 1998)

Employer Safety and Health Committee Information Package

(PDF File: 5 pages; 37K; Last revised March 25, 1998)

Information package to assist employers in complying with the state’s Safety & Health Committee regulations, along with the Commission’s required Inspection Form.

Employer Self-Insurance Application Package (PDF File: 25 pages; 380K; Last revised April 21, 2014)

Employer Self-Insurance Application Package

(PDF File: 25 pages; 380K; Last revised April 21, 2014)

Information package for employers wishing to self-insure their workers’ compensation liabilities, along with the required forms and documents.

Form 1A (PDF File: 1 page; 78K; Last revised July 13, 2009)

Form 1A

(PDF File: 1 page; 78K; Last revised July 13, 2009)

The Form 1A “FILING STATUS AND EXEMPTION FORM” identifies the claimant’s tax filing status last filed prior to the date of injury, and must be completed and submitted on all initial Voluntary Agreements for injuries occurring on or after October 1, 1991. See below for the “VOLUNTARY AGREEMENT” FORM.

Form 6B, 6B-1 and 75 Directions (PDF File: 1 page; 59K; Last revised July 15, 2013)

Form 6B, 6B-1 and 75 Directions

(PDF File: 1 page; 59K; Last revised July 15, 2013)

Form 6B, 6B-1 and 75 Directions “ELECTION OF WORKERS’ COMPENSATION COVERAGE FOR CERTAIN EMPLOYEES UNDER THE WORKERS’ COMPENSATION ACT OR REVOCATION OF PREVIOUS ELECTION OF SUCH COVERAGE” provides directions for filing the 6B, 6B-1, and 75 forms (below) used by various persons when electing to be covered under the Connecticut Workers’ Compensation Act or when revoking a previous election of such coverage.

Form 6B (PDF File: 1 page; 75K; Last revised July 15, 2013)

Form 6B

(PDF File: 1 page; 75K; Last revised July 15, 2013)

The Form 6B “COVERAGE ELECTION BY EMPLOYEE WHO IS AN OFFICER OF A CORPORATION, MANAGER OF AN LLC, OR MEMBER OF A MULTIPLE-MEMBER LLC” is to be completed by an Officer of a Corporation, a Manager of a Limited Liability Company (LLC), or a Member of a Multiple-Member Limited Liability Company (LLC) who wishes to be excluded from workers’ compensation insurance coverage. It is also used for such an officer, manager, or member to revoke any previous election of exclusion from workers’ compensation coverage.

[NOTE: Read the Form 6B, 6B-1 and 75 Directions (above) for complete instructions regarding the filing of this form.]

Form 6B-1 (PDF File: 1 page; 75K; Last revised July 15, 2013)

Form 6B-1

(PDF File: 1 page; 75K; Last revised July 15, 2013)

The Form 6B-1 “COVERAGE ELECTION BY EMPLOYEES WHO ARE MEMBERS OF A PARTNERSHIP” is to be completed by all members of a partnership who wish to be excluded from workers’ compensation insurance coverage. It is also used for such members to revoke any previous election of exclusion from workers’ compensation coverage.

[NOTE: Read the Form 6B, 6B-1 and 75 Directions (above) for complete instructions regarding the filing of this form.]

Form 7A-7B-7C Directions (PDF File: 1 page; 142K; Last revised March 17, 2006)

Form 7A-7B-7C Directions

(PDF File: 1 page; 142K; Last revised March 17, 2006)

The Form 7A-7B-7C Directions “BUILDING PERMIT REQUIREMENTS FOR WORKERS’ COMPENSATION” provides directions for filing the 7A, 7B, and 7C forms (below) used by various persons when applying for a building permit.

Form 7A (PDF File: 1 page; 160K; Last revised March 17, 2006)

Form 7A

(PDF File: 1 page; 160K; Last revised March 17, 2006)

The Form 7A “PROOF OF WORKERS’ COMPENSATION COVERAGE WHEN APPLYING FOR A BUILDING PERMIT FOR THE SOLE PROPRIETOR OR PROPERTY OWNER WHO WILL NOT ACT AS GENERAL CONTRACTOR OR PRINCIPAL EMPLOYER” is to be completed by the sole proprietor or property owner who is applying for a building permit, and who will not act as general contractor or principal employer. The Form 7A is to be submitted to the local building official to whom you are applying for a building permit, and not to the Workers’ Compensation Commission.

[NOTE: Read the Form 7A-7B-7C Directions (above) for complete instructions regarding the filing of this form.]

Form 7B (PDF File: 1 page; 180K; Last revised March 17, 2006)

Form 7B

(PDF File: 1 page; 180K; Last revised March 17, 2006)

The Form 7B “PROOF OF WORKERS’ COMPENSATION COVERAGE WHEN APPLYING FOR A BUILDING PERMIT FOR THE SOLE PROPRIETOR OR PROPERTY OWNER WHO WILL ACT AS GENERAL CONTRACTOR OR PRINCIPAL EMPLOYER” is to be completed by the sole proprietor or property owner who is applying for a building permit, and who will act as general contractor or principal employer. The Form 7B is to be submitted to the local building official to whom you are applying for a building permit, and not to the Workers’ Compensation Commission.

[NOTE: Read the Form 7A-7B-7C Directions (above) for complete instructions regarding the filing of this form.]

Form 7C (PDF File: 1 page; 183K; Last revised March 17, 2006)

Form 7C

(PDF File: 1 page; 183K; Last revised March 17, 2006)

The Form 7C “PROOF OF WORKERS’ COMPENSATION COVERAGE WHEN APPLYING FOR A BUILDING PERMIT FOR THE GENERAL CONTRACTOR OR PRINCIPAL EMPLOYER WHO HAS CHOSEN TO BE EXCLUDED FROM COVERAGE” is to be completed by the general contractor or principal employer who is applying for a building permit, and who has chosen to be excluded from workers’ compensation coverage by filing a form 6B or form 6B-1 (above) with the Workers’ Compensation Commission. The Form 7C is to be submitted to the local building official to whom you are applying for a building permit, and not to the Workers’ Compensation Commission.

[NOTE: Read the Form 7A-7B-7C Directions (above) for complete instructions regarding the filing of this form.]

Form 30C (PDF File: 4 pages; 1.27MB; Last revised August 23, 2010)

Form 30C

(PDF File: 4 pages; 1.27MB; Last revised August 23, 2010)

The Form 30C “NOTICE OF CLAIM FOR COMPENSATION (EMPLOYEE TO COMMISSIONER AND TO EMPLOYER)” is to be completed and filed by a claimant (employee) or claimant’s attorney/representative for making a claim for workers’ compensation benefits. The Form 30C includes a map of Connecticut’s 169 cities and towns and their respective workers’ compensation districts, as well as instructions for completing and filing this form and a listing of district office contact information.

Form 30D (PDF File: 5 pages; 1.0MB; Last revised July 13, 2009)

Form 30D

(PDF File: 5 pages; 1.0MB; Last revised July 13, 2009)

The Form 30D “DEPENDENT'S NOTICE OF CLAIM (TO COMMISSIONER AND TO EMPLOYER)” is to be completed and filed by a dependent or dependent’s attorney/representative for making a claim for workers’ compensation death benefits pursuant to Section 31-306 of the Workers’ Compensation Act. The Form 30D includes a map of Connecticut’s 169 cities and towns and their respective workers’ compensation districts, as well as instructions for completing and filing this form and a listing of district office contact information.

Form 36 (PDF File: 1 page; 96K; Last revised July 13, 2009)

Form 36

(PDF File: 1 page; 96K; Last revised July 13, 2009)

The Form 36 “NOTICE OF INTENTION TO REDUCE OR DISCONTINUE PAYMENTS” is to be completed by the respondent (employer/workers’ compensation insurance carrier) to notify the Workers’ Compensation Commissioner, the claimant (employee/decedent), and all parties to the claim of its intention to reduce or discontinue payment of the claimant’s workers’ compensation benefits.

Form 42 (PDF File: 1 page; 228K; Last revised September 3, 2010)

Form 42

(PDF File: 1 page; 228K; Last revised September 3, 2010)

The Form 42 “PHYSICIAN’S PERMANENT IMPAIRMENT EVALUATION” is to be completed by the examining licensed physician to report a claimant’s permanent partial loss or loss of use of a body part, as well as the likely date of the claimant’s maximum medical improvement.

Form 43 (PDF File: 1 page; 72K; Last revised July 13, 2009)

Form 43

(PDF File: 1 page; 72K; Last revised July 13, 2009)

The Form 43 “NOTICE TO COMPENSATION COMMISSIONER AND EMPLOYEE OF INTENTION TO CONTEST EMPLOYEE’S RIGHT TO COMPENSATION BENEFITS” is to be completed by the respondent (employer/workers’ compensation insurance carrier) to notify the Workers’ Compensation Commissioner, the claimant (employee/decedent), and all parties to the claim of its intention to deny the compensability of all or part of the claimant’s claim to workers’ compensation benefits.

Form 44 (PDF File: 1 page; 68K; Last revised July 13, 2009)

Form 44

(PDF File: 1 page; 68K; Last revised July 13, 2009)

The Form 44 “ORDER TO SECOND INJURY FUND IN CASES OF CONCURRENT EMPLOYMENT” is to be completed by a workers’ compensation insurance carrier seeking reimbursement from the state Second Injury Fund. Once both the carrier and the Fund agree on the figures and sign the form, it is sent to the Commission for approval.

[NOTE: Read Memorandum No. 2004-04 for complete instructions regarding the filing of this form.]

Form 75 (PDF File: 1 page; 77K; Last revised July 15, 2013)

Form 75

(PDF File: 1 page; 77K; Last revised July 15, 2013)

The Form 75 “COVERAGE ELECTION BY SOLE PROPRIETOR OR SINGLE-MEMBER LLC” is to be completed by a Sole Proprietor of a business or a Single-Member Limited Liability Company (LLC) who wishes to be included for workers’ compensation insurance coverage. It is also used for such a sole proprietor or member to revoke any previous election of inclusion for workers’ compensation coverage.

[NOTE: Read the Form 6B, 6B-1 and 75 Directions (above) for complete instructions regarding the filing of this form.]

Form 98 (PDF File: 1 page; 45K; Last revised April 29, 2008)

Form 98

(PDF File: 1 page; 45K; Last revised April 29, 2008)

The Form 98 “MANDATORY NOTICE TO DEPENDENTS BY EMPLOYER OR INSURER TO BE FILED UPON DEATH OF EMPLOYEE WHO IS RECEIVING WEEKLY DISABILITY BENEFITS” is to be completed by an employer or its workers’ compensation insurance carrier to notify surviving dependents of a deceased employee of their possible eligibility for dependents’ benefits under the Workers’ Compensation Act.

Form WCR-1 (PDF File: 1 page; 72K; Last revised July 13, 2009)

Form WCR-1

(PDF File: 1 page; 72K; Last revised July 13, 2009)

The Form WCR-1 “REHABILITATION REQUEST” should be completed by the injured employee, or another party referring the injured employee, to apply for workers’ rehabilitation benefits administered by the Workers’ Compensation Commission. The form must be signed by the injured employee.

Hearing Cancellation Request (PDF File: 1 page; 228K; Last revised January 17, 2007)

Hearing Cancellation Request

(PDF File: 1 page; 228K; Last revised January 17, 2007)

The “HEARING CANCELLATION REQUEST” Form is to be completed by any party to a claim or his/her attorney/representative who wishes to cancel a previously-scheduled Informal or Pre-Formal hearing before a Workers’ Compensation Commissioner.

[NOTE: Read about the Hearing Cancellation Request Form for Informal and Pre-Formal Hearings BEFORE using this form!]

Hearing Request (PDF File: 1 page; 77K; Last revised July 13, 2009)

Hearing Request

(PDF File: 1 page; 77K; Last revised July 13, 2009)

The “HEARING REQUEST” Form is to be completed by any party to a claim or his/her attorney/representative who wishes to request a hearing before a Workers’ Compensation Commissioner.

Mileage Worksheet for Medical Treatment - Examination - Physical Therapy - Laboratory Test (PDF File: 1 page; 89K; Last revised March 17, 2006)

Mileage Worksheet for Medical Treatment - Examination - Physical Therapy - Laboratory Test

(PDF File: 1 page; 89K; Last revised March 17, 2006)

The “MILEAGE WORK SHEET FOR MEDICAL TREATMENT/EXAM/PHYSICAL THERAPY/LABORATORY TEST” provided here may be used by an employee to report mileage incurred due to workers’ compensation-related medical appointments.

[NOTE: For complete information regarding this, refer to the Information Packet, below. Also read about Public Act 01-33 for up-to-date mileage reimbursement rate information.]

Notice to Employees (PDF File: 1 page; 183K; Last revised August 31, 2004)

Notice to Employees

(PDF File: 1 page; 183K; Last revised August 31, 2004)

The “NOTICE TO EMPLOYEES” must be completed and posted in a conspicuous place in each place of employment in Connecticut.

Notification of Appearance (PDF File: 1 page; 200K; Last revised March 17, 2006)

Notification of Appearance

(PDF File: 1 page; 200K; Last revised March 17, 2006)

The “NOTIFICATION OF APPEARANCE” Form is to be completed by the attorney/representative of any party to a claim to notify the Workers’ Compensation Commission regarding who will be representing the party before the Commission.

Petition for Review (PDF File: 1 page; 202K; Last revised March 17, 2006)

Petition for Review

(PDF File: 1 page; 202K; Last revised March 17, 2006)

The “PETITION FOR REVIEW” Form is to be completed by any party to a claim or his/her attorney/representative who wishes to file an appeal with the Workers’ Compensation Commission’s Compensation Review Board (CRB).

Record of Employment Contacts (PDF File: 1 page; 68K; Last revised July 8, 2005)

Record of Employment Contacts

(PDF File: 1 page; 68K; Last revised July 8, 2005)

The “RECORD OF EMPLOYMENT CONTACTS” Form provided here (from the Information Packet, below) may be used by an employee to report contacts with employers during a job search while the employee is out on workers’ compensation.

[NOTE: For complete information regarding this, refer to the Information Packet, below.]

Stipulation Approval Procedure (PDF File: 1 page; 23K; Last revised January 29, 2009)

Stipulation Approval Procedure

(PDF File: 1 page; 23K; Last revised January 29, 2009)

The “STIPULATION APPROVAL PROCEDURE” form is a purely informational document which outlines the procedures to take prior to requesting a Stipulation Hearing (including steps taken by a pro se or out-of-state claimant) and describes what occurs at a Stipulation Hearing.

Stipulation and What It Means (PDF File: 1 page; 98K; Last revised June 6, 2003)

Stipulation and What It Means

(PDF File: 1 page; 98K; Last revised June 6, 2003)

The “STIPULATION AND WHAT IT MEANS” form is to be signed by the claimant, stating that he or she agrees to close out the case as a full and final settlement. This form should be submitted with Stipulation paperwork prior to requesting a Stipulation Hearing.

Stipulation TO DATE and What It Means (PDF File: 1 page; 99K; Last revised June 6, 2005)

Stipulation TO DATE and What It Means

(PDF File: 1 page; 99K; Last revised June 6, 2005)

The “STIPULATION TO DATE AND WHAT IT MEANS” form is to be signed by the claimant as a compromise of contested benefit claims up to the date of approval, and should be submitted with Stipulation paperwork prior to requesting a Stipulation Hearing.

Stipulation Questionnaire (PDF File: 1 page; 27K; Last revised January 30, 2009)

Stipulation Questionnaire

(PDF File: 1 page; 27K; Last revised January 30, 2009)

The “STIPULATION QUESTIONNAIRE” form contains questions that must be answered and submitted with Stipulation papers prior to requesting a Stipulation Hearing. Medical bills, liens, and other relevant information regarding unpaid fees must be attached to the form, unless such documents have already been submitted.

Voluntary Agreement (PDF File: 2 pages; 490K; Last revised May 7, 2014)

Voluntary Agreement

(PDF File: 2 pages; 490K; Last revised May 7, 2014)

The “VOLUNTARY AGREEMENT” Form contains important information (including benefit calculations) regarding an injured employee’s claim, and should be completed and issued by the injured employee’s employer or its workers’ compensation insurance carrier in every case in which an injured or ill employee receives workers’ compensation payments. It must also be accompanied by the “FILING STATUS AND EXEMPTION FORM” (Form 1A), above.

[NOTE: This form will be accepted on GREEN stock only.]

WCC Education Services Order Form (PDF File: 1 page; 43K; Last revised May 13, 2014)

WCC Education Services Order Form

(PDF File: 1 page; 43K; Last revised May 13, 2014)

Print this form and send it in to receive more information from the Commission.

Workers’ Compensation District Map (PDF File: 1 page; 920K; Last revised May 1, 2006)

Workers’ Compensation District Map

(PDF File: 1 page; 920K; Last revised May 1, 2006)

A printable map of Connecticut’s workers’ compensation districts by city and town, effective May 1, 2006.

Workers’ Compensation Information Packet (PDF File: 41 pages; 2.15MB; Last revised May 14, 2014)

Workers’ Compensation Information Packet

(PDF File: 41 pages; 2.15MB; Last revised May 14, 2014)

Comprehensive “plain-English” information about Connecticut’s workers’ compensation system, its benefits, procedures, and more. Includes a number of fillable and sample workers’ compensation forms.

Workers’ Compensation Commission

Page last revised: September 5, 2014

Page URL: http://wcc.state.ct.us/download/forms.htm

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State of Connecticut Workers' Compensation Commission, John A. Mastropietro, Chairman
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General Information Glossary Law CRB Opinions Workers' Compensation Commission Downloadable Forms and Publications Links