Form 30C and 30D Revised


TO: WCC Administrative Law Judges, District Administrators, Claimants, Self-Insureds, Insurance Carriers, Attorneys, Unions, and Advisory Board Members
FROM: Stephen M. Morelli, Chairman
DATE: June 3, 2022
RE: Forms 30C and 30D Revised


Pursuant to Public Act 22-139, the Workers’ Compensation Commission (WCC) is required to maintain and report a record of all workers’ compensation cancer claims made by firefighters. In order to accurately collect and record this data, WCC Form 30C “Notice of Claim for Compensation” and Form 30D “Dependents’ Notice of Claim” have been revised. The revision of WCC Form 30C also includes a change to reflect post-traumatic stress injuries made pursuant to C.G.S. Section 31-294k. Please use the most recent revisions of Forms 30C and 30D and check the appropriate box(es) when filing new claims. The revised forms can be obtained below or from our Online Forms page.

Form 30C (PDF File: 4 pages; Last revised June 1, 2022)

Form 30D (PDF File: 5 pages; Last revised June 1, 2022)