Notice Of Claim For Compensation {30C}

INJURYDate of InjuryTown of InjuryBody Part(s)Describe Injury and How It Happened: þ Check, if an Occupational Disease or a Repetitive Trauma þ Check, if you have MORE THAN ONE Employer þ þ þ þ þ þ þ þ þ þ þ 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 WCC use only) 30CNotice 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.WCC File # Please TYPE or PRINT IN INKRev. 07-01-2019State of Connecticut Workers222 Compensation Commission INJURED WORKER NameD.O.B. Check, if a Minor þ þ þ þ þ Address Town þ State Zip Code þ Tel.# EMPLOYEREmployerAddress Town þ State Zip Code þ Tel.# Was Injury ON Premises of Employer? þ YES þ þ NOIf NO, where?AddressTown Zip Code þ Tel.# SIGNATURE OF INJURED WORKER OR REPRESENTATIVEDate þ þ þ þ þ þ þ þ þ NameName of FirmAddress Town þ State Zip Code þ Tel.# * þ Persons employed by the State of Connecticut must serve the employer by serving this notice upon the Commissioner of Administrative Services, þ 450 Columbus Boulevard, Hartford, CT 06103. * þ Persons employed by a municipality must serve the employer by serving this notice upon the town clerk of the municipality in which he or she is employed. þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ WARNING: þ payments 223without e when this claim is received by personal delivery or by registered or 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 workers222 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 employer222s 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 workers222 compensation claim. A simple 223accident report224 filed with the employer is not an official claim for workers222 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 workers222 compensation benefit payments 223without prejudice.224 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. (If your employer has opted to post a location where you must file your claim, this 28-day period begins when your employer has received your claim at the location posted per statute.) Directions for Completing the 30C Claim Form Please pay close attention to these directions. Remember to Type or Print Neatly In Ink (except for signatures). In filling out the 30C Form, please note the following: 1. In the 223INJURED WORKER224 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 worker222s 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 worker222s street address, town, state, zip code, and telephone number. 2. In the 223EMPLOYER224 box at the lower left side of the form, type or neatly print the name of the employer (223Name of employer224 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 worker222s injury occurred at the employer222s 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 223INJURY224 box at the upper right side of the form, type or neatly print the date of the injured worker222s 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 employer222s business address!). Indicate the part(s) of the worker222s body injured and how the injury occurred (In the blank space describe your injury in simple terms, specifying the part(s) of your body affected and the type(s) of injury. For example: 223sprain to the right shoulder224, 223amputation of the left thumb224, 223fracture of the right ankle224, 223severe strain to lower back224, etc.). Next check the first box, if the injury is an occupational disease or a repetitive trauma , check the second box if you have more than one employer , and check the third box if you are a police officer, parole officer, or firefighter claiming benefits for PTSD pursuant to Public Act 19-17 . 4. In the 223SIGNATURE OF INJURED WORKER OR REPRESENTATIVE224 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, town, state, zip code, and your telephone number. 5. In the 223WCC File #224 box at the upper right side of the form (just below the 22330C224 number in the upper right corner), type or neatly print the WCC File Number, ONLY IF YOU KNOW IT . In most instances, this number will be assigned to your claim by the Workers222 Compensation Commission only after you send the 30C Form in, so it is okay to leave this one area of the form blank, if you are not absolutely sure of the number. Once you have completed the 30C Form, follow these procedures: 6. Make two (2) extra copies of your completed 30C Form (this can be done at many quick-copy printers). 7. Send the original 30C to your employer* by Certified or Registered mail, return receipt requested. The claim may also be delivered in person but if so, have the employer acknowledge in writing the receipt of the claim . * State employees222 work-related injuries and illnesses are reported on Form PER-WC 207, entitled 223Report of Occupational Injury or Disease to an Employee224. If a State employee elects to file a 30C Form, then he or she must send the 30C Form to the Commissioner of Administrative Services, 450 Columbus Boulevard, Hartford, CT 06103, NOT to the particular office where employed. (The Form PER-WC 207 is ONLY an accident report and is NOT the official claim form for workers222 compensation benefits 227 State employees, like any other employees, must file a 30C Form in order to file an official workers222 compensation claim.) * Municipal employees, like any other employees, must file a 30C Form in order to file an official workers222 compensation claim; if a municipal employee elects to file a 30C Form, then he or she must send the 30C Form to the town clerk of the municipality in which he or she is employed. * Employees (other than State or municipal employees): if your employer pursuant to statute has posted the location where you must file a 30C Form, it is your obligation to file it at that location, using certified mail. 8. Send a copy of the 30C to the appropriate Workers222 Compensation Commission District Office by Certified or Registered mail, return receipt requested, or deliver by personal presentation . Addresses for all Workers222 Compensation Commission District Offices may be fo