Claim Forms
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.
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.
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