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Connecticut Form Center -

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Form

Description

fri.pdf Employer's First Report of Occupational Injury or Illness
HIPAARel.pdf Authorization for Release of Medical Records
work-status.pdf Employee Medical and Work Status Form
ppo-app.pdf Employer Medical Care Plan Application Package
shpacket.pdf Employer Safety and Health Committee Information Package
si-app.pdf Employer Self-Insurance Application Package
1a.pdf Filing Status and Exemption
6b-6b1-75-dir.pdf Election of Workers' Compensation Coverage for Certain Employees under the Workers' Compensation Act OR Revocation of Previous Election of Such Coverage
6b.pdf Coverage Election by Employee who is an Officer of a Corporation, Manager of an LLC, or Member of a Multiple-Member LLC
6b-1.pdf Coverage Election by Employees who are Members of a Partnership
7a.pdf Proof of Workers' Compensation Coverage when Applying for a Building Permit for the Sole Proprietor or Property Owner who will not act as General Contractor or Principal Employer
7b.pdf Proof of Workers' Compensation Coverage when Applying for a Building Permit for the Sole Proprietor or Property Owner who will act as General Contractor or Principal Employer
7c.pdf Proof of Workers' Compensation Coverage when Applying for a Building Permit for the General Contractor or Principal Employer who has Chosen to be Excluded from Coverage.
7dir.pdf Directions for 7a - 7b - 7c. Building Permit Requirements for Workers' Compensation.
30c.pdf Notice of Claim for Compensation
30d.pdf Dependents Notice of Claim
36.pdf Notice to Employee and Compensation Commissioner of Intention to Discontinue and Reduce Payments
42.pdf Physicians Permanent Impairment Evaluation
43.pdf Notice to Employee and Compensation Commissioner of Intention to Contest Employees Right to Compensation Benefits
44.pdf Order to Second Injury Fund in Cases of Concurrent Employment
75.pdf Coverage Election by Sole Proprietor or Single-Member LLC
98.pdf Notice to Dependents
WCR-1.pdf Rehabilitation Request
hc.pdf Hearing Cancellation Request
hr.pdf Hearing Request Form
mileage.pdf Mileage Work Sheet for Medical Treatment/Exam/Physical Therapy/Laboratory Test
notice.pdf POSTER - Notice to Employees
noa.pdf Notification of Appearance
pfr.pdf Petition for Review
rec.pdf Record of Employment Contacts Form
sap.pdf Stipulation Approval Procedure
swim.pdf Stipulation and What it Means
stdwim.pdf Stipulation to Date and What it Means
cawim.pdf Commutation and What it Means
sq.pdf Stipulation Questionnaire
va.pdf Voluntary Agreement as to Workers' Compensation - This form will be accepted on GREEN stock only
client_handbook.pdf Workers' Rehabilitation Services Client Handbook
employer_packet.pdf Workers' Rehabilitation Services On-The-Job Training Employer Information Packet
es-order.pdf WCC Education Services Order Form
distmap.pdf Workers' Compensation District Map
Info-Packet.pdf BROCHURE - Workers' Compensation Information Packet
Info-Packet-sp.pdf BROCHURE - Workers' Compensation Information Packet (Spanish)
pocket-guide.pdf An Employee's Pocket Guide To Connecticut Workers' Compensation
pocket-guide-sp.pdf An Employee's Pocket Guide To Connecticut Workers' Compensation (Spanish)