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		(HIPAARel) Authorization for Release of Medical Records - 6/04
		(fri) Employer’s First Report of Occupational Injury or Illness - 7/09
		(1a) Filing Status and Exemption - 10/06
		(6b) Coverage Selection Form For Employee / Member or Partnership - 7/09
		(6b-1) Coverage Selection Form For Employee / Member or Partnership) - 7/09
		(30c) Notice of Claim for Compensation - 4/09
		(30d) Dependents Notice of Claim - 4/09
		(36) Notice to Employee and Compensation Commissioner of Intention to Discontinue and Reduce Payments - 10/07
		(42) Physicians Permanent Impairment Evaluation - 7/09
		(43) Notice to Employee and Compensation Commissioner of Intention to Contest Employees Right to Compensation Benefits - 3/06
		(44) Order to Second Injury Fund in Cases of Concurrent Employment - 3/06
		(75) Notice to Commissioner of Intention to be Included for Coverage - 7/06
		(7a) Proof of workers’ compensation coverage when applying for a building permit for the sole proprietor or property owner who will not act as general contractor or principal employer. - 3/06
		(7b) Proof of workers’ compensation coverage when applying for a building permit for the sole proprietor or property owner who will act as general contractor or principal employer. - 3/06
		(7c) Proof Of Workers’ Compensation Coverage When Applying For A Building Permit For The General Contractor Or Principal Employer Who Has Chosen To Be Excluded From Coverage. - 3/06
		(7dir) Directions for 7a - 7b - 7c. Building Permit Requirements For Workers’ Compensation. - 3/06
		(98) Notice to Dependents - 4/08
		(WCR-1) Rehabilitation Request - 7/09
		(hr) Hearing Request Form - 10/07
		(hc) Hearing Cancellation Request - 1/07
		(mileage) Mileage Work Sheet for Medical Treatment/Exam/Physical Therapy/Laboratory Test - 3/06
		(noa) Notification of Appearance - 3/06
		(pfr) Petition for Review - 3/06
		(rec) Record Of Employment Contacts Form - 7/05
		(va) Voluntary Agreement as to Workers Compensation - 8/09
		(es-order) WCC Education Services Order Form - 10/05
		(cawim) Commutation And What It Means - 6/06
		(notice) The “NOTICE TO EMPLOYEES” must be completed and posted in a conspicuous place in each place of employment in Connecticut. - 8/04
		(sap) The “STIPULATION APPROVAL PROCEDURE” form is a purely informational document which outlines the procedures to take prior to requesting a Stipulation Hearing (including steps taken by a pro se or out-of-state claimant) and describes what occurs at a hearin
		(sq) The “STIPULATION QUESTIONNAIRE” form contains questions that must be answered and submitted with Stipulation papers prior to requesting a Stipulation - Hearing. Medical bills, liens, and other relevant information regarding unpaid fees. - 1/09
		(stdwim) The “STIPULATION TO DATE AND WHAT IT MEANS” form is to be signed by the claimant as a compromise of contested benefit claims up to the date of approval, and should be submitted with Stipulation paperwork prior to requesting a Stipulation Hearing. -
		(swim) The “STIPULATION AND WHAT IT MEANS” form is to be signed by the claimant, stating that he or she agrees to close out the case as a full and final settlement. This form should be submitted with Stipulation paperwork prior to requesting a Stipulation Hearin
		(distmap) A printable map of Connecticut’s workers’ compensation districts by city and town, effective May 1, 2006. - 5/06
		(Info-Packet) Workers' Compensation Information Packet - 8/09
		(shpacket) Employer Safety and Health Committee Information Package - 03/98
		(si-app) Employer Self-Insurance Application Package - 10/02
		(ppo-app) Employer Medical Care Plan Application Package - 12/01
		(HIPAARel) Authorization For Release Of Medical Records By A Hospital/Provider - 7/09

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