Workers' Compensation Forms

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• Forms : Employer Applications

  Application materials for employers to apply to operate a workers' compensation Medical Care Plan, to Self-Insure their workers' compensation liabilities, and to meet Employer Safety & Health Committee requirements.

• Forms : Coverage Election Forms

  Forms 6B, 6B-1, and 75, used for certain employees to elect to be covered under the Connecticut Workers’ Compensation Act or when revoking a previous election of such coverage.

• Forms : Medical Forms

  Medical-related forms, including the Authorization for Release of Medical Records, Employee Medical & Work Status, and Physician’s Permanent Impairment Evaluation (42) forms.

• Forms : Employer Forms

  Forms 43, 98, and First Report of Injury (FRI), as well as the state's required "Notice to Employees" to be posted in all employer workplaces in Connecticut.

• Forms : Hearing Forms

  Hearing Request (HR), Notification of Appearance (NOA), Hearing Cancellation Request (HC), and Petition for Review (PFR) hearing-related forms.

• Forms : Building Permit Forms

  Forms 7A, 7B, and 7C, dealing with building permit requirements for workers' compensation, including directions for their usage.

• Forms : Claim Forms

  Forms 30C and 30D, for making an official claim for workers' compensation benefits.

• Forms : Rehabilitation Forms

  Form WCR-1, rehabilitation program application form.

• Forms : Insurance Forms

  Forms 36 and 44, dealing with insurance aspects of workers' compensation.

• Forms : Stipulation & Commutation Forms

  Stipulation Approval Procedure, Stipulation And What It Means, Stipulation TO DATE And What It Means, Stipulation Questionnaire, and Commutation And What It Means forms.

• Forms : Voluntary Agreement Forms

  Voluntary Agreement (VA) and Filing Status And Exemption (1A) forms.

• Forms : Worksheets

  Unofficial, but useful, claimant worksheets.