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FORM: 1A - Filing Status and Exemption Connecticut Workers' Compensation Commission Agency Forms 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your personal information in the EMPLOYEE section. Fill in your name, optional Social Security number, address, city/town, state, and zip code.
- In the FILING STATUS AND EXEMPTIONS section, select your Federal tax filing status that matches your actual status as of the date of injury. Choose from Single, Head of Household, Married filing jointly, or Married filing separately.
- Indicate the number of exemptions you are claiming as of the date of injury. This includes yourself.
- Answer whether FICA was withheld for you by selecting YES or NO. If NO is selected, note that the insurer will manually calculate your weekly benefit rate.
- Check any applicable boxes regarding age or blindness for yourself or spouse.
- List all exemptions included in question #2 with their names, dates of birth, and relationships to you.
- If applicable, provide details about concurrent employment by listing each employer's name and address along with your date of hire.
- Finally, sign and date the form to attest that all information provided is correct.
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What is the form for workers comp claims in CT?
The Form 30C is to be completed and filed by a claimant (employee) or claimants attorney/representative for making a claim for workers compensation benefits.
What is a Form 43 Connecticut?
The Form 43 is to be completed by the respondent (employer/workers compensation insurance carrier) to notify the Administrative Law Judge, the claimant (employee/decedent), and all parties to the claim of its intention to deny the compensability of all or part of the claimants claim to workers compensation benefits.
What is a Form 43 in CT?
The Form 43 is to be completed by the respondent (employer/workers compensation insurance carrier) to notify the Administrative Law Judge, the claimant (employee/decedent), and all parties to the claim of its intention to deny the compensability of all or part of the claimants claim to workers compensation benefits.
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People also ask
What is the CT workers comp exclusion form?
The Form 6B is to be completed by an Officer of a Corporation or a Manager of a Limited Liability Company (LLC) who wishes to be excluded from workers compensation insurance coverage. It is also used for such an officer or manager to revoke any previous election of exclusion from workers compensation coverage.
What is a Form 6B in CT?
Form 6B, 6B-1 and 75 Directions for filing the forms 6B, 6B-1, and 75 (below) used when electing to be covered under the Connecticut Workers Compensation Act or when revoking a previous election of such coverage. Form 6B.
Who is exempt from workers comp in CT?
There are a few exceptions to who Connecticut considers an employee, such as: Casual employees. Employees working in a private home for less than 26 hours a week. Corporate officers who choose not to have coverage.
How to file for workers compensation 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.
What is Form 36 in CT WC?
The Form 36 is to be completed by the respondent (employer/workers compensation insurance carrier) to notify the Workers Compensation Commissioner, the claimant (employee/decedent), and all parties to the claim of its intention to reduce or discontinue payment of the claimants workers compensation benefits.
Related links
The Filing Status and Exemption(s) indicated at left MUST reflect employees. Federal tax status for the Date of Injury provided here. This formRead more
May 2, 2017 Do not use these forms to report wages subject to U.S. income tax withholding. Instead, use Form W-2 to show U.S. income tax withheld. TreatmentRead more