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 below.
Building Permit Forms
Claim Forms
Coverage Election Forms
Employer Applications
Employer Forms
Hearing Forms
Insurance Forms
Medical Forms
Rehabilitation Forms
Stipulation and Commutation Forms
Voluntary Agreement Forms
Worksheets
Building Permit Forms
- Form 7A-7B-7C Directions (PDF)
- Form 7A (PDF) : 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
- Form 7B (PDF) : 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
- Form 7C (PDF) : 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
Claim Forms
- Form 30C (PDF) : Notice of Claim for Compensation
- Form 30D (PDF) : Dependent's Notice of Claim for Compensation
Coverage Election Forms
- Form 6B, 6B-1 and 75 Directions (PDF)
- Form 6B (PDF) : Coverage Election by Employee who is an Officer of a Corporation or a Manager of an LLC
- Form 6B-1 (PDF) : Coverage Election by Employees who are Members of a Partnership
- Form 75 (PDF) : Coverage Election by Sole Proprietor
Employer Applications
- Employer Medical Care Application (PDF)
- Employer Safety and Health Committee Information Package (PDF)
- Employer Self-Insurance Application (PDF)
Employer Forms
- Form 43 (PDF) : Notice to Administrative Law Judge and Employee of Intention to Contest Employee's Right to Compensation Benefits
- Form 98 (PDF) : Mandatory Notice to Dependents by Employer or Insurer to be filed upon Death of Employee who is receiving Weekly Disability Benefits
- Employer's First Report of Occupational Injury or Illness (PDF)
- Notice to Employees (PDF)
Hearing Forms
- Hearing Request (PDF)
- Petition for Review (PDF)
- Notification of Appearance (PDF)
- Hearing CANCELLATION Request (PDF)
Insurance Forms
- Form 36 (PDF) : Notice of Intention to Reduce or Discontinue Payments
- Form 44 (PDF) : Order to Second Injury Fund in Cases of Concurrent Employment
Medical Forms
- Authorization for Release of Medical Records (PDF)
- Employee Medical & Work Status Form (PDF)
- Form 42 (PDF) : Physician’s Permanent Impairment Evaluation
Rehabilitation Forms
- WCR-1 (PDF) : Rehabilitation Request
Stipulation & Commutation Forms
- Stipulation Approval Procedure (PDF)
- Stipulation and What It Means (PDF)
- Stipulation and What It Means (Spanish) (PDF)
- Indemnity Only Stipulation and What it Means (PDF)
- Stipulation TO DATE and What It Means (PDF)
- Stipulation Questionnaire (PDF)
- Commutation and What It Means (PDF)
Voluntary Agreement Forms
- Voluntary Agreement (PDF)
- Form 1A (PDF) : Filing Status And Exemption Form
Worksheets
- Mileage Worksheet for Medical Treatment, Examination, Physical Therapy, or Laboratory Test (PDF)
- Record of Employment Contacts (PDF)