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Please TYPE or PRINT IN INK 30C Rev. 3-17-2006 State of Connecticut Workers Compensation Commission WCC File # Notice of Claim for Compensation Date filed in District (Employee to Commissioner and

How to fill out workers comp 30c form

How to fill out a workers comp 30c form:

1. Start by gathering all the necessary information. You will need details about the injured employee, such as their name, date of birth, and job title. Additionally, gather information about the employer and any witnesses to the incident.
2. Begin filling out the top section of the form, which asks for general information about the claim. This includes the employer's name, address, and workers' compensation policy number.
3. Move on to section A, where you will provide details about the injured employee. Include their full name, contact information, and social security number, as well as their role within the company.
4. In section B, you will describe the injury or illness that occurred. Be as detailed as possible, including the date and time of the incident, how it occurred, and any contributing factors.
5. Section C requires information about the medical treatment the employee received. Include the name and contact details of the healthcare provider, as well as the dates of treatment and any medications prescribed.
6. Next, in section D, provide details about the employee's work status after the incident. Indicate whether they were able to continue working, if modified duties were provided, or if they were unable to work at all.
7. Section E is for the signature and contact information of the person completing the form. Sign and date the form and provide your name, title, and phone number for any follow-up questions.
8. Finally, review the completed form for accuracy and make copies for your records before submitting it to the appropriate workers' compensation office.

Who needs workers comp 30c form?

1. Employers: Employers are required to fill out a workers comp 30c form whenever an employee suffers a work-related injury or illness. It is important for employers to accurately document the incident and provide necessary details related to the employee, the injury, and the subsequent treatment.
2. Employees: Injured employees also have a role in the workers comp process. They need to ensure that the form is properly filled out by their employer and includes all relevant information about their injury or illness. The workers comp 30c form helps employees seek compensation for medical treatment, lost wages, and other related expenses resulting from their work-related injury or illness.

For pdfFiller’s FAQs

What is workers comp 30c form?

Workers comp 30c form is a document used to report work-related injuries and illnesses to the workers' compensation board.

Who is required to file workers comp 30c form?

Employers are required to file workers comp 30c form when an employee sustains a work-related injury or illness.

How to fill out workers comp 30c form?

Workers comp 30c form can be filled out by providing details about the injured employee, the nature of the injury, and the circumstances surrounding the incident.

What is the purpose of workers comp 30c form?

The purpose of workers comp 30c form is to ensure that injured employees receive the necessary benefits and medical treatment as required by law.

What information must be reported on workers comp 30c form?

Information such as employee details, date and time of the incident, description of the injury, and any witnesses to the incident must be reported on workers comp 30c form.

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