The 30C Form: Notice of Claim for Compensation

When an employee is injured or becomes ill as a result of their employment, the Workers’ Compensation Act (Sec. 31-294c) requires that he/she notify their employer of their intention to file a workers’ compensation claim. The law allows the employee 1 year from the date of injury or 3 years from the 1st manifestation of a symptom of an occupational disease in which to do this. Although the employer files a First Report of Injury to notify the insurer, it is the Form 30C, which is filed by the injured worker and served upon the employer, which satisfies this statutory requirement. (You can find copies of these forms in the Forms section beginning on page 24 of this Packet.)

As soon as the employer receives this notice of claim, they should forward it to the insurer in order to allow them time to make a determination as to the compensability of the claim. The employer/insurer then has 28 days in which to commence payment for lost time (if any), or deny the claim. If they do neither within that period of time, they lose their right to contest the claim, thereby accepting responsibility. If payments are begun within the 28 days, the employer/insurer then has up to ONE YEAR in which to contest the claim, should circumstances warrant.

Voluntary Agreement [Sec. 31-296]

If the injury/illness disables the claimant for more than 3 days and the insurance company does not deny the claim, they must issue a Voluntary Agreement (VA), which is a statement of acceptance of responsibility for the claim. The VA must be signed by all parties and approved by an Administrative Law Judge.

The law requires the insurance company to issue this Voluntary Agreement. If you do not receive a VA within a month from the date of your disability, you should call the insurance company and request that they issue one to you. It is your right and their responsibility under the law.

The official State of Connecticut Workers’ Compensation Voluntary Agreement form is green. (We have included a COPY of the Voluntary Agreement in the Forms section of this Packet beginning on page 24, so you will know what it looks like.)

To the Claimant: Filing an Official Workers’ Compensation Claim (30C Form)

If you are injured on the job or are diagnosed as having a work-related disease, you should file a written notice of claim for workers’ compensation as soon as possible. The 30C is the official form which the Workers’ Compensation Commission provides for this purpose. (There is a 30C form which you may use, as well as line-byline directions for completing it, in the Forms section on page 24 of this Packet.)

A Form 30C should be filed promptly after a work-related injury takes place. There is a statute of limitation for filing workers’ compensation claims: within ONE YEAR of the date of an injury or within THREE YEARS of the first manifestation of a symptom of an occupational disease. Neither the First Report of Injury nor the employer’s accident report satisfies this statutory requirement.

The 30C Form must be sent by registered or certified mail to both your employer and the Workers’ Compensation Commission District Office which has jurisdiction over the city or town in which you were injured or became ill; NOT the town in which you live. You must ask for a return receipt from the Post Office as proof of the date that it was received. You may also deliver it in person. If you do, you must have your employer sign and date the form as proof of their receipt.

(See pages 21-23 of this Packet for a complete list of Connecticut cities and towns and the District Offices which have jurisdiction over them for workers’ compensation claims.)

You should file a 30C Claim Form because:

1. It is the best way to insure that you have met the statute of limitations for filing a workers’ compensation claim.
2. A simple “accident report” filed with your employer is NOT an official claim for workers’ compensation benefits.
3. Your claim will be more likely to receive prompt attention from your employer or insurance carrier.
4. Once your employer receives an official claim, it has only 28 calendar days in which to either deny your claim or to begin making workers’ compensation benefit payments “without prejudice.” If an official denial is not issued within 28 calendar days or if benefit payments are not initiated within 28 calendar days, your employer MUST accept the compensability of your claim. (If your employer has opted to post a location where you must file your claim, this 28-day period begins when your employer has received your claim at the location posted.)

If you are injured on the job, follow the proper procedures to protect your rights!

First Report your injury immediately to your employer, who must then provide you with proper medical attention. Do not delay in reporting workplace injuries. Many claimants are initially denied benefits because they did not report their injuries immediately.

Second File a proper written notice of claim—a 30C Form—as soon as possible! This is YOUR RESPONSIBILITY! A 30C Form has been included in this packet for your convenience.

Third Ask your employer for the name of their workers’ compensation insurance company. Follow the directions and, if you need assistance, call our toll-free number in Connecticut at 1-800-223-WORK (9675) or call 860-493-1500 and ask to speak to an Education Coordinator.