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

Claim Forms

 

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.

 


 

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.

Get the Adobe Acrobat Reader by clicking the following button:   Get Adobe Acrobat Reader

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.