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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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