Connecticut State Department of Emergency Services and Public Protection

Workers' Compensation

For Assistance:  860-807-6932

 

Send Documents/Medicals to:

  DAS Public Safety Fax Number:  1-860-707-1846

Email:  DAS_RfaxWCPS@ct.gov

 

Medical Claim Contact:  860-256-3409

Denise Miller  860-256-3453

 

State of Connecticut Workers’ Compensation Claim Reporting Packet
The following is a general-purpose description of each form within the Workers' Compensation Claim Packet: Click on the form link for a writable PDF version.
Authorization For Release of Medical Records - May be used by any hospital or provider for the purpose of administering a Connecticut Workers’ Compensation claim for benefits.
DAS Form 207-1 -Supervisor’s Accident Investigation Report (Civilian) : The Supervisor must complete this form with the employee and then forward it to the Human Resources office, along with the 207 report, within 24 hours after the incident.
DAS Form 207 - First Report of Injury: Supervisor, together with the injured employee, completes the form and sends it to the DPS Workers' Compensation Liaison.
DAS Form 208 - Worker Status Report: This form is completed by the initial care or attending physician to record the injured workers diagnosis, course of treatment and work disposition. Employee provides this form to the physician and returns it completed to the Third Party Claim Administrator (TPA) within twenty-four (24) hours of the office visit.
DAS Form PER-WC 211 - Concurrent Employment and Third Party Liability: Completed by injured employee to identify if he/she has any employment other than the State of Connecticut for potential concurrent employment benefits and to identify any third party negligence-giving rise to the injury. Employee forwards completed form to the DPS Workers' Compensation Liaison for processing.
DAS Form WC-715 - Request for Use of Accrued Leave With Workers' Compensation: This form is completed by the agency in conjunction with the injured employee to designate his/her election to utilize or not utilize accrued leave during the interim period and/or to supplement lost wage workers' compensation benefits on an approved workers' compensation claim. Employee forwards completed form to the DPS Workers' Compensation Liaison for processing.
Hearing Request - This 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/Exam/Physical Therapy/Laboratory Test - May be used by an employee to report mileage incurred due to workers’ compensation-related medical appointments.  See Public Act 01-33 for up-to-date mileage reimbursement rate information.
WCC Form 1A - Filing Status and Exemption: Injured employee, or representative, fills out this Workers’ Compensation Commission form to record his/her federal income tax filing status and number of exemptions for use in establishing the base Workers’ Compensation rate. Employee forwards completed form to the DPS Workers' Compensation Liaison for processing.
WCC Form 30C - Notice of Claim for Compensation is to be completed and filed by the injured employee, or employee’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.
Recurrence Claims - Must be reported to supervisor.