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Notice to Dependants - Connecticut

Notice to Dependants - Connecticut 2025

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The document is a notice from the Connecticut Workers' Compensation Commission informing the dependents of an employee who may have died due to a work-related injury about their potential eligibility for dependents' benefits. It outlines the requirement to file a written notice of claim within specified time limits and advises contacting the commission or a legal advisor for further assistance.

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Click ‘Get Form’ to open the Notice to Dependants - Connecticut in the editor.
Begin by entering the name of the employee in the designated field at the top of the form. This identifies who the notice pertains to.
Next, fill in the employee's address accurately. This information is crucial for proper communication regarding benefits.
Indicate the date of injury in the specified section. Ensure this date aligns with your records for consistency.
Review any additional instructions regarding filing a written notice of claim. Make sure you understand the time limits set forth in § 31-294c of the Connecticut General Statutes.
Finally, complete the section indicating who is sending this notice, including their name and address, and ensure you enter the date when this notice is being sent.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I extend my CT paid leave?

If you are an employee of the State of Connecticut who is in a position that is covered by a collective bargaining agreements, you are not covered under CT Paid Leave unless your bargaining unit collectively bargains to be included. This means you do not contribute to the program, and you are not eligible for benefits.

How long can I receive CT paid leave?

Workers who are eligible for CT Paid Leave and have a qualifying reason may receive up to 12 weeks of paid leave benefits in a 12-month period for most* leave reasons. An additional 2 weeks may be available during pregnancy.

How to file a workers comp claim in CT?

Promptly file a Written Notice of Claim: In Connecticut, you must file Form 30C, which gives notice to the Workers Compensation Commission that you are claiming benefits. Although you notified your employer that you were injured, you must file the Written Notice, Form 30C, as well.

How long can you take CT paid leave?

In all cases, the weekly benefit is capped at 60 times the CT minimum wage (i.e. $981 as of 1/1/2025).