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 57 State Forms found

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Employer's First Report of Occupational Injury or Illness

 FRI Rev. 7-13-2009

Notice of Claim for Compensation (Employee to Administrative Law Judge and to Employer)

 30C Rev. 06-14-2024

Physician's Permanent Impairment Evaluation

 42 Rev. 11-3-2023

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS BY A HOSPITAL/PROVIDER FOR THE PURPOSE OF ADMINISTERING A CONNECTICUT WORKERS’ COMPENSATION CLAIM FOR BENEFITS

 No Form Number Revised November 23, 2009

COMMUTATION AND WHAT IT MEANS

No Form Number Rev. 08-19-2022

Coverage Election by Employee who is an Officer of a Corporation or a Member of an LLC

 6B Rev. 12-15-2022

Coverage Election by Employees Who are Members of a Partnership

 6B-1 Rev. 12-15-2022

Coverage Election by Sole Proprietor

 75 Rev. 12-15-2022

Dependent’s Notice of Claim (To Administrative Law Judge and to Employer)

 30D Rev. 06-14-2024

Employee Medical & Work Status Form

 No Form Number Rev. 9-26-2011

Implementation of Safety & Health Connecticut Administrative Regulations 31-40v-1 through 31-40v-11

 No Form Number Last revised March 25, 1998

INFORMATION ON SELF-INSURANCE/APPLICATION FOR CERTIFICATE OF SELF-INSURANCE

 No Form Number Rev. 03/01/22

Filing Status and Exemption

1A Rev. 7-13-2009

Building Permit Requirements for Workers’ Compensation

 7A-7B-7C DIRECTIONS Rev. 3-17-2006

Hearing CANCELLATION Request

 HC Rev. 10-01-2021
Disclaimer: These forms may not be the most recent version. Connecticut may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on this site. Please check official sources.
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