Connecticut > Workers Compensation
Notice Of Claim For Compensation (Employee To Commissioner And To Employer) 30C - Connecticut
| Notice Of Claim For Compensation (Employee To Commissioner And To Employer) Form. This is a Connecticut form and can be used in Workers Compensation . |
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State of Connecticut Workers' Compensation Commission Please TYPE or PRINT IN INK 30C Date filed in District (for WCC use only) Notice of Claim for Compensation (Employee to Commissioner and to Employer) This form prepared by the WCC is proper for ordinary use and is recommended, but any other notice complying with Section 31-294c shall be deemed sufficient. Notice is hereby given that the injured worker, while in the employ of the employer, sustained injuries arising out of and in the course of his/her employment as follows, and makes claim for compensation benefits. INJURED WORKER Name (first) (middle) (last) INJURY Date of Injury Town of Injury D.O.B. (required) Body Part(s) Describe Injury and How It Happened: Check, if a Minor (under 18 yrs. of age) Address Town State Check, if an Occupational Disease or a Repetitive Trauma Zip Code Tel.# Check, if you have MORE THAN ONE Employer EMPLOYER Employer SIGNATURE OF INJURED WORKER OR REPRESENTATIVE Signature Address Date Town Zip Code Was Injury ON Premises of Employer? If NO, where? Address Town Zip Code Tel.# Tel.# YES NO State Print name & address below, if other than injured worker: Name Name of Firm Address Town Zip Code Tel.# State This notice must be served upon the Commissioner and *Employer by personal presentation or by registered or certified mail. For the protection of both parties, the employer should note the date when this notice was received and the claimant should keep a copy of this notice with the date it was served. * Persons employed by the State of Connecticut must also serve the employer by serving this notice upon the Commissioner of Administrative Services, 165 Capitol Avenue, Hartford, CT 06106. WARNING: If an employer does not file a notice contesting liability (e.g. Form 43) for this claim OR begin making workers' compensation benefit payments "without prejudice" within 28 calendar days from the date when this claim is received by personal delivery or by registered or certified mail, COMPENSABILITY SHALL BE PRESUMED and cannot thereafter be contested. If an employer chooses to begin making workers' compensation benefit payments "without prejudice" within 28 calendar days from the date of receipt of this claim and still wishes to contest this claim, it must do so by filing a notice contesting liability for this claim within one year from receipt of this claim. [See Sec. 31-294c(b).] American LegalNet, Inc. www.FormsWorkFlow.com Rev. 8-23-2010 WCC File # 1 5 8 3 4 State of Connecticut Workers' Compensation Districts [effective 5-1-06] 6 2 7 American LegalNet, Inc. www.FormsWorkFlow.com A 30C Form should be filed promptly after a work-related injury or illness takes place. There is a statute of limitation for filing workers' compensation claims: within one year of the date of an accidental injury or within three years from the first manifestation of a symptom of an occupational disease. [NOTE: If, within the applicable time period described above, (1) there has been a hearing or a written request for a hearing or an assignment for a hearing or (2) your employer's insurance carrier has already signed a Voluntary Agreement, you do NOT need to file a 30C Form for the injury or illness it covers.] You Should File A 30C Form Because . . . · · · · · There will be no doubt that you are claiming that you have a work-related injury or occupational disease. It is the best way to insure that you have met the statute of limitations for filing a workers' compensation claim. A simple "accident report" filed with the employer is not an official claim for workers' compensation. Your claim will be more likely to receive prompt attention from your employer or insurance carrier. Once your employer receives an official claim, they have only 28 calendar days in which to either deny your claim or to begin making workers' compensation benefit payments "without prejudice." If an official denial is not issued within 28 calendar days or if benefit payments are not initiated within 28 calendar days, your employer must accept the compensability of your claim. Directions for Completing the 30C Claim Form Please pay close attention to these directions. When filling out a 30C Form, remember to Type or Print Neatly In Ink (except for signatures). In filling out the 30C Form, please note the following: 1. In the "INJURED WORKER" box at the upper left side of the form, type or neatly print the name of the injured worker (If YOU are the injured worker, print YOUR name here.). Also fill in the injured worker's D.O.B. (date of birth), put a check in the box, if the worker is a minor (under the age of 18) and fill in the injured worker's street address, town, state, zip code, and telephone number. 2. In the "EMPLOYER" box at the lower left side of the form, type or neatly print the name of the employer ("Name of employer" means the name of the organization for which you work, NOT your boss or supervisor.) and its street address, town, state, zip code, and telephone number. Next indicate (YES or NO) whether the injured worker's injury occurred at the employer's location just listed; if the injury took place at a location other than that listed, fill in the location, street address, town, state, zip code, and telephone number where the injury actually occurred. 3. In the "INJURY" box at the upper right side of the form, type or neatly print the date of the injured worker's injury and the town in which the injury occurred (Note the city or town in which the injury actually occurred. This will not necessarily be the same location as the employer's business address!). Next indicate the part(s) of the worker's body injured and how the injury occurred (In the blank space describe your injury in simple terms. Indicate the part(s) of your body affected and the type(s) of injury. For example: "sprain to the right shoulder", "amputation of the left thumb", "fracture of the right ankle", "severe strain to lower back", etc.). Lastly, indicate (YES or NO) whether the injury is an occupational disease or a repetitive trauma, and check the appropriate box, if you have more than one employer. 4. In the "SIGNATURE OF INJURED WORKER OR REPRESENTATIVE" box at the lower right side of the form, sign your name and fill in the date of your signature, if you are the injured worker. If you are NOT the injured worker, then sign your name, fill in the date of your signature, and then type or neatly print your name, the name (if any) of your firm, your street address,
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