In observance of Thanksgiving, WCC offices will be closed on Thursday, November 24, 2022.

Workers' Compensation Forms

 

This section of the Commission's website contains all the official forms created by, and used in the daily operations of, the Workers' Compensation Commission.

All parties within the State of Connecticut's workers' compensation system should use the official forms provided here, in order to ensure the documents you use are:

  • up-to-date;
  • accurate; and
  • meet statutory requirements

The Commission's online forms are available in PDF format, and most have the ability to be filled out online, printed, and saved.

Forms, Directions and Worksheets are sorted by topic using the list of links to the left and are also sorted alphanumerically below. 


link opens in new browser tab  Form 1A

PDF File: 1 page; Last revised July 13, 2009
 

Filing Status And Exemption Form

The Filing Status And Exemption Form 1A 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.


link opens in new browser tab  Form 6B, 6B-1 and 75 Directions

PDF File:  1 page; Last revised June 17, 2019
 

Election of Workers' Compensation Coverage for Certain Employees under the Workers' Compensation Act OR Revocation of Previous Election of Such Coverage

Form 6B, 6B-1 and 75 Directions for filing the forms 6B, 6B-1, and 75 (below) used when electing to be covered under the Connecticut Workers’ Compensation Act or when revoking a previous election of such coverage.


link opens in new browser tab  Form 6B

PDF File:  1 page; Last revised June 17, 2019
 

Coverage Election by Employee who is an Officer of a Corporation or a Manager of an LLC

The Form 6B is to be completed by an Officer of a Corporation or a Manager of a Limited Liability Company (LLC) who wishes to be excluded from workers’ compensation insurance coverage.

It is also used for such an officer or manager to revoke any previous election of exclusion from workers’ compensation coverage.


link opens in new browser tab  Form 6B-1

PDF File:  1 page; Last revised July 15, 2015
 

Coverage Election by Employees who are Members of a Partnership

The Form 6B-1 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.


link opens in new browser tab  Form 7A-7B-7C Directions

PDF File:  1 page; Last revised March 17, 2006
 

Building Permit Requirements for Workers' Compensation

This document provides directions for filing the forms 7A, 7B, and 7C (below) used when applying for a building permit.


link opens in new browser tab  Form 7A

PDF File:  1 page; Last revised March 17, 2006
 

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

The Form 7A 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.

It 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.


link opens in new browser tab  Form 7B

PDF File:  1 page; Last revised March 17, 2006
 

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

The Form 7B 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.

It 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.


link opens in new browser tab  Form 7C

PDF File:  1 page; Last revised March 17, 2006
 

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

The Form 7C 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 with the Workers' Compensation Commission.

It 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.


link opens in new browser tab  Form 30C

PDF File:  4 pages; Last revised June 1, 2022
 

Notice of Claim for Compensation  (Employee to Administrative Law Judge and to Employer)

The Form 30C 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.


link opens in new browser tab  Form 30D

PDF File:  5 pages; Last revised June 1, 2022
 

Dependent's Notice of Claim for Compensation  (To Administrative Law Judge and to Employer)

The Form 30D 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.


link opens in new browser tab  Form 36

PDF File:  1 page; Last revised October 1, 2021
 

Notice of Intention to Reduce or Discontinue Payments

The Form 36 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.


link opens in new browser tab  Form 42

PDF File:  1 page; Last revised September 3, 2010
 

Physician’s Permanent Impairment Evaluation

The Form 42 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.


link opens in new browser tab    Form 43

PDF File:  1 page; Last revised October 1, 2021
 

Notice to Administrative Law Judge and Employee of Intention to Contest Employee's Right to Compensation Benefits

The Form 43 is to be completed by the respondent (employer/workers’ compensation insurance carrier) to notify the Administrative Law Judge, 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.


link opens in new browser tab  Form 44

PDF File:  1 page; Last revised July 13, 2009
 

Order to Second Injury Fund in Cases of Concurrent Employment

The Form 44 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.]


link opens in new browser tab  Form 75

PDF File:  1 page; Last revised June 17, 2019
 

Coverage Election by Sole Proprietor

The Form 75 is to be completed by a Sole Proprietor of a business who wishes to be included for workers’ compensation insurance coverage.

It is also used for such a sole proprietor to revoke any previous election of inclusion for workers’ compensation coverage.


link opens in new browser tab    Form 98

PDF File:  1 page; Last revised April 29, 2008
 

Mandatory Notice to Dependents by Employer or Insurer to be filed upon Death of Employee who is receiving Weekly Disability Benefits

The Form 98 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.


link opens in new browser tab  Authorization for Release of Medical Records

PDF File:  1 page; Last revised November 23, 2009
 

Authorization for Release of Medical Records by a Hospital/Provider for the purpose of Administering a Connecticut Workers’ Compensation Claim for Benefits

The Authorization for Release of Medical Records form may be used by any hospital or provider for the purpose of administering a Connecticut workers’ compensation claim for benefits.


link opens in new browser tab  Commutation and What It Means

PDF File: 1 page; Last revised August 19, 2022
 

Commutation And What It Means

The form Commutation And What It Means explains what a commutation is, and must 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.


link opens in new browser tab  Employee Medical & Work Status Form

PDF File:  1 page; Last revised September 26, 2011
 

Workers' Compensation - Employee Medical & Work Status Form

The Workers' Compensation - Employee Medical & Work Status Form 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  link opens in new browser tab  Payor and Medical Provider Guidelines publication, which describes the purpose and proper use of this form.]


link opens in new browser tab    Employer's First Report of Occupational Injury or Illness

PDF File:  1 page; Last revised July 13, 2009
 

Employer's First Report of Occupational Injury or Illness

The Employer's First Report of Occupational Injury or Illness form 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 of Occupational Injury or Illness form must be sent directly to the Commission Chairman's Office in Hartford.

[NOTE: For more information, see Section 31-316 of the Workers' Compensation Act.]


link opens in new browser tab  Employer Medical Care Application

PDF File:  23 pages; Last revised October 1, 2021
 

Employer Medical Care Application Information Packet

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.


link opens in new browser tab  Employer Safety and Health Committee Information Package

PDF File:  5 pages; Last revised March 25, 1998
 

Implementation of Safety & Health Connecticut Administrative Regulations 31-40v-1 through 31-40v-11

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


link opens in new browser tab  Employer Self-Insurance Application

PDF File:  25 pages; Last revised August 24, 2022
 

Information on Self-Insurance

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


link opens in new browser tab  Hearing CANCELLATION Request

PDF File:  1 page; Last revised October 1, 2021
 

Hearing CANCELLATION Request

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 an Administrative Law Judge. (It is not to be used for a Formal hearing.)

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


link opens in new browser tab  Hearing Request

PDF File:  1 page; Last revised July 13, 2009
 

Hearing Request

The Hearing Request form is to be completed by any party to a claim or his/her attorney/representative who wishes to request an Informal, Pre-Formal, Formal, Stip Approval, or Disfigurement/Scar hearing before an Administrative Law Judge in one of the Commission's eight District Offices.


link opens in new browser tab  Mileage Worksheet

PDF File:  1 page; Last revised March 17, 2006
 

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

Although not an official Commission form, we provide this worksheet to injured employees who might need such a worksheet to report mileage incurred due to workers’ compensation-related medical appointments.

[NOTE: For complete information regarding this, refer to the    link opens in new browser tab  Info Packet and see also Public Act 01-33 for up-to-date mileage reimbursement rate information.]


link opens in new browser tab    Notice to Employees

PDF File:  1 page; Last revised October 1, 2021
 

Notice to Employees

The Notice to Employees must be completed and posted in a conspicuous place in each place of employment in Connecticut.

If an employer chooses to designate a location for employee claims pursuant to Public Act 17-141, this notice must be posted where other posters required by law are displayed in the workplace.

[NOTE: For complete information regarding an employer-designated location for employee claims, refer to Memorandum No. 2017-08]


link opens in new browser tab  Notification of Appearance

PDF File:  1 page; Last revised March 17, 2006
 

Notification of Appearance

The Notification of Appearance form must be completed by the attorney/representative of any party to a claim to notify the Workers’ Compensation Commission of who will be representing that particular party before the Commission.


link opens in new browser tab  Petition for Review

PDF File:  1 page; Last revised October 1, 2021
 

Petition for Review

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).


link opens in new browser tab  Record of Employment Contacts

PDF File:  1 page; Last revised July 8, 2005
 

Record of Employment Contacts

Although not an official Commission form, we provide this worksheet to injured employees who might need such a worksheet 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    link opens in new browser tab  Info Packet]


link opens in new browser tab  Stipulation Approval Procedure

PDF File: 1 page; Last revised October 1, 2021
 

Stipulation Approval Procedure

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.


link opens in new browser tab  Stipulation and What It Means

PDF File: 1 page; Last revised October 1, 2021
 

Stipulation And What It Means

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.


link opens in new browser tab  Stipulation TO DATE and What It Means

PDF File: 1 page; Last revised August 19, 2022
 

Stipulation TO DATE And What It Means

The Stipulation TO DATE And What It Means form must 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


link opens in new browser tab  Stipulation Questionnaire

PDF File: 1 page; Last revised August 25, 2022
 

Stipulation Questionnaire

The Stipulation Questionnaire form contains questions that must be answered and submitted with Stipulation papers prior to requesting a Stipulation Hearing. Information regarding medical bills, liens, and other unpaid fees must be attached to the form (unless such documents have already been submitted).


link opens in new browser tab  Voluntary Agreement

PDF File: 2 pages; Last revised May 7, 2014
 

Voluntary Agreement

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.

Every Voluntary Agreement must be accompanied by the Filing Status And Exemption Form 1A, below.


link opens in new browser tab  WCR-1

PDF File:  1 page; Last revised July 13, 2009
 

Rehabilitation Request

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.


 

 

The Workers' Compensation Commission recommends the use of Adobe's free Adobe Acrobat Reader software application when accessing or using its PDF forms and publications.

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The Workers' Compensation Commission's recommendation of Adobe's free Adobe Acrobat Reader software application is based solely on technical considerations inherent in the PDF files this agency produces, and does not constitute an endorsement of Adobe Software as a company or of its commercially-available products. There are a multitude of free and commercial software applications offered by various software makers that are capable of opening and displaying our PDF documents, but only the Adobe Acrobat Reader application makes full and accurate use of the capabilities we have built into our documents; the agency has found over a period of many years that the Adobe Acrobat Reader provides the best, most trouble-free experience using this Commission's PDF files.