State of Connecticut Workers' Compensation Commission, John A. Mastropietro, Chairman
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Workers' Compensation Glossary: F


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Filing Status and Exemption Form

Workers' Compensation Commission Form WCC-1A used by an employee with a compensable work-related injury or occupational disease ON OR AFTER October 1, 1991 to report federal tax filing status and number of claimed exemptions for determining workers' compensation benefits.

First Report of Injury

Workers' Compensation Commission Form WCC-15 (for non-State employees) or State of Connecticut Form PER WC-207 (for State employees) required to be filed by an employer in cases of an employee's occupational injury or disease that results in incapacity from work of one day or more.

Form 27-62

Workers' Compensation Commission form used by the Workers' Compensation Commission Chairman authorizing an employer to self-insure its workers' compensation insurance coverage liability.

Form 30C

Workers' Compensation Commission form serving as a proper written notice of claim for workers' compensation benefits.

Form 36

Workers' Compensation Commission form used by an employer or its workers' compensation insurance carrier to discontinue or reduce a claimant's workers' compensation benefit payments.

Form 42

Workers' Compensation Commission form used by an attending physician to report the existence and extent of a Permanent Partial Disability of an employee with a compensable work- related injury or occupational disease.

Form 43

Workers' Compensation Commission form used by an employer or its workers' compensation insurance carrier to deny or contest liability for a claim for workers' compensation benefits.

Form 44

Workers' Compensation Commission form used by a Workers' Compensation Commissioner to order payment by the State's Second Injury Fund of workers' compensation benefits to a claimant or as reimbursement to an employer or its workers' compensation insurance carrier for benefits already paid to a claimant.

Form 47

Workers' Compensation Commission form used by a Workers' Compensation Commissioner to award disfigurement or scarring benefits to an employee with a compensable work-related injury or occupational disease.

Form 48

Workers' Compensation Commission form used by an attending physician to report initial medical findings related to an employee's compensable work-related injury or occupational disease.

Form 49

Workers' Compensation Commission form used by an attending physician to report medical findings related to an employee's compensable work-related injury or occupational disease during the course of treatment.

Form 6B-1

Workers' Compensation Commission form used by a partnership to elect exclusion from workers' compensation insurance coverage or to revoke a previous election of exclusion.

Form 6B

Workers' Compensation Commission form used by a corporate officer to elect exclusion from workers' compensation insurance coverage or to revoke a previous election of exclusion.

Form 75

Workers' Compensation Commission form used by a sole proprietor of a business to elect inclusion for workers' compensation insurance coverage or to revoke a previous election of inclusion.

Form PER WC-207

State of Connecticut form required to be filed by the State of Connecticut in cases of a State employee's occupational injury or disease that results in incapacity from work of one day or more.

Form PER WC-208

State of Connecticut form used by an attending physician to report initial medical findings related to a State employee's compensable work-related injury or occupational disease.

Form WC18-76

Workers' Compensation Commission form used by an employer to apply for a Certificate of Solvency from the Commission.

Form WCC-15

Workers' Compensation Commission form required to be filed by an employer (other than the State of Connecticut) in cases of an employee's occupational injury or disease that results in incapacity from work of one day or more.

Form WCC-1

Workers' Compensation Commission form serving as an agreement between an employer's workers' compensation insurance carrier or a self-insured employer and an employee with a compensable work- related injury or occupational disease specifying the type and amount of workers' compensation benefit to be paid to the employee.

Form WCC-1A

Workers' Compensation Commission form used by an employee with a compensable work-related injury or occupational disease ON OR AFTER October 1, 1991 to report federal tax filing status and number of claimed exemptions for determining workers' compensation benefits.

Form WCR-1

Workers' Compensation Commission form used by an employee with a compensable work-related injury or occupational disease to request vocational rehabilitation services from the Commission's Division of Workers' Rehabilitation or by any other party referring such an employee to the Division for such services.

Form: Commutation and What It Means

Workers' Compensation Commission form signed by a claimant to signify understanding of and agreement to payment of workers' compensation benefits by commutation.

Form: Informal Hearing Request

Workers' Compensation Commission form used by any party requesting an Informal Hearing before a Workers' Compensation Commissioner.

Form: Notice to Employees

Workers' Compensation Commission notice required in each employer's workplace to notify its employees of its workers' compensation insurance coverage.

Form: Petition for Review

Workers' Compensation Commission form used by any party requesting an appeal before the Commission's Compensation Review Board.

Form: Stipulation and What It Means

Workers' Compensation Commission form signed by a claimant signifying understanding of and agreement to a final settlement of a workers' compensation case by stipulation.

Formal Hearing

Formal meeting between the parties in a workers' compensation case and presided over by a Workers' Compensation Commissioner for the purpose of resolving differences, disagreements, and the like to provide appropriate workers' compensation benefits to a claimant. Witnesses in Formal Hearings are sworn and testify and evidence is introduced, resulting in a binding written decision by the presiding Commissioner. Usually held in a Workers' Compensation Commission District Office, a Formal Hearing is the second level hearing available to adverse parties in a workers' compensation case and is scheduled when disputes cannot be resolved in any earlier Informal Hearing(s). There may be one or, more infrequently, two Formal Hearings in a workers' compensation case. Written decisions from Formal Hearings may be appealed to the Compensation Review Board.

Fraud Unit

The Workers' Compensation Fraud Unit within the Chief State's Attorney's Office, Division of Criminal Justice, which investigates complaints of workers' compensation fraud and takes appropriate action to enforce Connecticut law.


A B C D E F G H I J K L M N O P Q R S T U V W X Y Z


State of Connecticut Workers' Compensation Commission, John A. Mastropietro, Chairman
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Page last revised: April 1, 1997
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