Coverage Election
FRI
Hearing forms
Medical
Notice to Employees
Payment disputes or reductions
Second Injury Fund
Where can insurance carriers find and request important forms and file a First Report of Injury (FRI)?
Get important insurance carrier forms below.
The Connecticut Workers’ Compensation Commission recommends you use these forms to make sure your paperwork is:
- Up to date
- Correct
- Follow the State’s laws
Most forms are PDFs you can fill out online, print, and save. Others, including Form 6B, you can send electronically.
Learn which forms to send with our Electronic Form Submission Service
Use GovQA to send forms, request important documents, verify coverage, and more
To sell workers’ comp insurance in CT, please visit the CT Insurance Department (CID).
Coverage Election
Form 1A: Filing Status and Exemption (PDF) - Shows a claimant’s tax filing status and exemptions for a workers’ compensation claim.
6B, 6B-1, and 75 directions: Election of Workers’ Compensation Coverage for Certain Employees under the Workers’ Compensation Act OR Revocation of Previous Election of Such Coverage (PDF) - The directions form explains how to fill out and send Forms 6B, 6B-1, and 75 to make or change coverage choices.
Form 6B: Coverage Election by Employee Who is an Officer of a Corporation or a Member of an LLC (PDF) - Lets a company officer or Limited Liability Corporation (LLC) manager say they don’t want workers’ comp coverage or take back that choice.
Form 6B-1: Coverage Election by Employees who are Members of a Partnership (PDF) - Lets partners in a business say they don’t want workers’ comp coverage or take back that choice.
Form 75: Coverage Election by Sole Proprietor (PDF) - Lets a sole business owner choose to have workers’ comp coverage or take back that choice.
Learn which forms to send with our Electronic Form Submission Service
Use GovQA to send forms, request important documents, verify coverage, and more
FRI
First Report of Injury (FRI) (PDF) - Tells WCC if a worker gets hurt or sick on the job and misses at least one day of work.
File an FRI with our Submission Service
Use GovQA to send forms, request important documents, verify coverage, and more
Hearing forms
Hearing Request (PDF) - Used to ask for a meeting with a judge about the claim.
Hearing Cancellation Request (PDF) - Used to cancel a meeting with a judge.
Notification of Appearance (PDF) - Shows who is officially helping in the case.
Petition for Review (PDF) - Use to file an appeal with the WCC Compensation Review Board (CRB).
Voluntary Agreement (PDF) - A signed paper showing everyone agrees on benefits.
Wage Statement (.doc) - Shows weekly pay for the year before the injury to figure out the workers’ comp check.
Learn which forms to send with our Electronic Form Submission Service
Use GovQA to send forms, request important documents, verify coverage, and more
Medical
Authorization for Release of Medical Records (PDF) - To ask for medical records for a workers’ comp claim.
Notice to Employees
Notice to Employees (PDF) - Employers post this form where workers can easily see it at every job site in Connecticut. For more information, refer to Memorandum No. 2017-08.
Learn how to submit Notice to Employees electronically with the Claim-Filing Employer Guide
Use GovQA to send forms, request important documents, verify coverage, and more
Payment disputes or reductions
Form 36: Notice of Intention to Reduce or Discontinue Payments (PDF) - Tells the worker the employer wants to stop or lower their payments.
Form 43: Notice to Administrative Law Judge and Employee of Intention to Contest Employee's Right to Compensation Benefits (PDF) - Says the employer doesn’t agree that the worker should get benefits.
Form 98: Mandatory Notice to Dependents by Employer or Insurer to be filed upon Death of Employee Who is Receiving Weekly Disability Benefits (PDF) - Notifies family when a worker who received payments has died.
Learn which forms to send with our Electronic Form Submission Service
Use GovQA to send forms, request important documents, verify coverage, and more
Second Injury Fund
Form 44: Order to Second Injury Fund in Cases of Concurrent Employment (PDF) - For insurers to ask the State’s Second Injury Fund to reimburse them.
Learn which forms to send with our Electronic Form Submission Service
Use GovQA to send forms, request important documents, verify coverage, and more