State of Connecticut Workers' Compensation Commission

MEMORANDUM NO. 2007-06

Form 30D

 

TO: Commissioners, District Administrators, Self-Insureds, Insurance Carriers, Attorneys, Unions, Legal Advisory Panel and Advisory Board Members
FROM: John A. Mastropietro, Chairman
DATE: September 24, 2007
RE: Form 30D

 

For the convenience of the parties, a "Dependent's Notice of Claim" form has now been established and designated as Form 30D, which is to be utilized by a dependent survivor who wishes to file a claim.

For your convenience, this form can be filled out and downloaded from our website at:

https://portal.ct.gov/-/media/WCC/forms/claim-forms/30d.pdf