Forms & Resources

Form 30C - The Form 30C is a formal notice of claim filed directly with your employer and the Workers’ Compensation Commission. In most cases, it must be filed no later than one (1) year from the date of injury. This document must be served in a specific manner and your attorney will file it on your behalf. Without this form properly completed, your claim is at risk of missing the statute of limitations.

Form 1A - The Form 1A is required for your weekly Workers’ Compensation benefit rate to be calculated. Although Workers’ Compensation benefits are non-taxable income, your tax filing status on this form affects the amount you are paid weekly while receiving benefits. Without this form completed correctly, you may be paid at an incorrect rate and the insurance company will not be able to formally accept your claim.

Authorization for Release of Medical Records - This form is simply a medical release. When an injured employee claims that a certain body part is injured at work, they are making their past medical history for that body part discoverable. Your employer’s insurance company is liable to bring you back to your medical “baseline” prior to your injury. In order for your “baseline” to be determined, your past medical history is required. Always be prepared to list your primary care physician and any other medical professional who has treated the injured body part(s) in your past.

Employee Medical & Work Status Form - This form is a generic work restriction form to be filled out by your physician after a work-related injury.  Many doctor offices have their own similar forms.  Should you be disabled from work, this form is required for an Administrative Law Judge to award you Workers’ Compensation benefits. Your work restrictions should be reassessed after each visit with your doctor in order to have your weekly benefits continued.

Form 42 - When disabled from work due to an injury, it is extremely rare that your lost time benefits will last forever. Temporary disability benefits will likely end once your doctor deems you at Maximum Medical Improvement. This means that the doctor thinks an employee’s recovery has plateaued. Once a doctor deems you at Maximum Medical Improvement, this form should be brought to the doctor so they may assign a permanent impairment percentage to your injured body part(s). The higher the percentage loss of use, the more benefits you will receive.

Mileage Worksheet - Injured employees with accepted claims are eligible to receive reimbursement for mileage traveled to and from medical treatment appointments. This form should be filled out and submitted to the insurance company so they may send you reimbursement. Mileage reimbursement rates typically change yearly. The following link breaks down the yearly rates:

Job Search Form - When an employee is injured and their doctor assigns them certain work restrictions, it is the employer’s choice as to whether they will accommodate the employee with a light duty position. If the employer chooses not to accommodate the injured employee, the employee is entitled to weekly disability benefits.  However, in order to receive these benefits, an employee must show that they are ready, willing, and able to work in our state. An employee must complete this form by applying for five (5) temporary jobs weekly within their restrictions and submit it to the insurance company. If your doctor deems you totally disabled, you do not have to search for jobs.

Short Term Disability (STD) -

You may be eligible for STD should your employer provide this benefit. You may have also purchased your own short-term disability policy. You should inquire with your employer whether this is available after being injured. These benefits will assist you if your case is being denied for any reason.

Connecticut Family and Medical Leave Act (CT FMLA) - You may be eligible for 12 weeks of job protection under CT FMLA. Contact your Human Resource department and your doctor’s office for FMLA paperwork to be completed. You must be reinstated to the same or an equivalent job with the same pay, benefits, and terms and conditions of employment on your return from FMLA-protected leave . Should you be disabled beyond 12 weeks, the employer may be able to terminate your employment.

Connecticut Paid Leave - CT employees pay 0.5% of their paychecks in order to fund this program. Should you be injured and disabled from work, applying to CT Paid Leave will assist you should your Workers’ Compensation case be denied, or take weeks to process. This program provides wage replacement benefits for up to 12 weeks. CT has partnered with Aflac, who will assign an adjuster to assist you in receiving your benefits.

Collective Bargaining Agreements/Employment Contracts - In addition to the benefits above, an injured employee should always look to their employment contract, as they often provide additional benefits/protections which our laws may not.

Collective Bargaining Agreements/Employment Contracts - In addition to the benefits above, an injured employee should always look to their employment contract, as they often provide additional benefits/protections which our laws may not.