Fill and Sign the Notice of Claim for Compensation Connecticut Form

WCC File #       DATE OF INJURY             TOWN OF INJURY       SOC. SEC. #       BODY PART             CHECK IF MINOR       ADDRESS                                      OCCUPATIONAL ILLNESS OR REPETITIVE TRAUMA?       EMPLOYER       ADDRESS                   TOWN                         NAME       NAME OF FIRM       ADDRESS       WAS INJURY ON PREMISES OF EMPLOYER?      IF NO, WHERE?       ADDRESS       TOWN              STATE                               30 C State of Connecticut Workers' Compensation Commission NOTICE 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 he deemed sufficient. PLEASE TYPE or PRINT IN INK 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 compensation benefits. 1 - INJURED WORKER INFORMATION 3- INJURY INFORMATION NAME (please type or print in ink) DESCRIBE INJURY AND HOW IT HAPPENED D.O.B. (under 18 yrs. of age) TOWN STATE ZIP TEL. # 2 - EMPLOYER INFORMATION 4 - SIGNATURE OF INJURED WORKER OR REPRESENTATIVE SIGNATURE DATE STATE ZIP Print name & address below, if other than injured worker: TEL. # ZIP TOWN STATE ZIP TEL. # This notice must be served upon the Commissioner and *Employer by personal presentation or by registered or certified mail. For the protection of the parties,the employer should note the date when this notice was received and the claimant should keep a copy of this notice with the date of service. *Persons employed by the State of Connecticut must also serve the employer by serving this notice upon the Commissioner of Administrative Services, 165 Capitol Avenue, Hartford, CT 06106. WARNING: If an employer does not file a notice contesting liability for this claim OR begin making workers' compensation benefit payments ''withoutprejudice'' within 28 calendar days from the date when this claim is received by personal delivery or by registered or certified mail,Compensability Shall Be Presumed and cannot thereafter be contested. If an employer chooses to begin making workers' compensation benefit payments ''without prejudice'' within 28 calendar days from the date of receipt of this claim and still wishes to contest this claim, itmust do so by filing a notice contesting liability for this claim within one year from receipt of this claim. [See Sec. 31-294c(b).] Rev. 3/16/98