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.
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.
Form 6B, 6B-1 and 75 Directions
PDF File: 1 page; Last revised December 15, 2022
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.
PDF File: 1 page; Last revised December 15, 2022
Effective December 15, 2022, Forms 6B can be filed electronically at: https://forms.office.com/g/MPrz0UL2sr.
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.
PDF File: 1 page; Last revised December 15, 2022
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.
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.
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.
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.
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.
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.
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.
PDF File: 1 page; Last revised November 3, 2023
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.
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.
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.]
PDF File: 1 page; Last revised December 15, 2022
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.
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.
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.
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.
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 Payor and Medical Provider Guidelines publication, which describes the purpose and proper use of this form.]
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.]
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.
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.
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.
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.]
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.
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 Info Packet and see also Public Act 01-33 for up-to-date mileage reimbursement rate information.]
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]
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.
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).
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 Info Packet]
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.
Stipulation and What It Means (Spanish)
PDF File: 1 page; Last revised September 21, 2022
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.
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
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).
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.
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.
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