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MEMORANDUM NO. 2024-04
Form Updates effective June 14, 2024
| TO: | WCC Administrative Law Judges, District Administrators, Advisory Board Members, Legal Advisory Panel, Medical Advisory Panel, Medical Practitioners, Insurance Carriers, Self-Insureds, Medical Care Plans, Claimants, Attorneys and Unions. |
| FROM: | Stephen M. Morelli, Chairperson |
| DATE: | June 14, 2024 |
| RE: | Form Updates effective June 14, 2024 |
Effective June 14, 2024, the following changes have been made to WCC forms:
- Form 30C has been updated with “Check, if Firefighter Cancer Claim pursuant to C.G.S. Chapter 568” and “Check, if Firefighter Cancer Claim pursuant to C.G.S. Section 7-313p” to help WCC better track Firefighter Cancer claims pursuant to Public Act No. 22-139. Language on Post Traumatic Stress Injuries has also been updated to reflect such injuries are pursuant to C.G.S. Section 31-294k.
- Form 30D has been updated with “Check, if Firefighter Cancer Claim pursuant to C.G.S. Chapter 568” and “Check, if Firefighter Cancer Claim pursuant to C.G.S. Section 7-313p” to help WCC better track Firefighter Cancer claims pursuant to Public Act No. 22-139.
- Hearing Request Form has been updated to allow the option for an email address to be added under the Injured Worker section.
- Voluntary Agreement Form has been updated with “Check, if C.G.S. Sec. 5-142”to help WCC better identify wage calculations which are pursuant to C.G.S. Sec. 5-142.
- WCR-1 : Rehabilitation Request Form has been updated with options to either fax or email the form to Rehabilitation Services in addition to mailing or submitting the form in-person. An optional line has also been added for applicants to add their email address.
Effective June 14, 2024, the following form is now available:
- Indemnity Only Stipulation and What it Means.
All forms can be found on WCC's website, here.