Connecticut Workers' Compensation Commission Poster Mandatory

NOTICE
State of Connecticut Workers’ Compensation Commission
The Workers’ Compensation Act (Connecticut General Statutes Chapter 568) requires your employer,
to provide benefits to you in case of injury or occupational disease in the course of employment.
Section 31-294b of the Workers’ Compensation Act states “Any employee who has sustained an injury 
in the course of his employment shall immediately report the injury to his employer, or some person 
representing  his  employer.  If  the  employee  fails  to  report  the  injury  immediately,  the  administrative 
law  judge  may  reduce  the  award  of  compensation  proportionately  to  any  prejudice  that  he  finds  the 
employer has sustained by reason of the failure, provided the burden of proof with respect to such 
prejudice shall rest upon the employer.”
An injury report by the employee is NOT an official written notice of claim for workers’ compensation 
benefits; the Workers’ Compensation Commission’s Form 30C is necessary to satisfy this requirement.
NOTE:	 You	must	comply	with	P.	A.	17-141	(see	next	box,	below)	when	filing	a	compensation	claim.
The INSURANCE COMPANY or SELF-INSURANCE ADMINISTRATOR is:
Name
Address Telephone
City/Town  State Zip Code
Approved Medical Care Plan  Yes No
The State of Connecticut Workers’ Compensation Commission office for this workplace is located at:
Address Telephone
City/Town  State Zip Code
Public Act 17-141 allows an employer the option to designate and post – “in the workplace location 
where  other  labor  law  posters  required  by  the  Labor  Department  are  prominently  displayed”  and  on 
the  Workers’  Compensation  Commission’s  website  [wcc.state.ct.us]  –  a  location  where  employees 
must file claims for compensation.
If your employer has listed a location below, you  MUST file your compensation claim there.
When filing your claim, you are also required – by law – to send it by certified mail.
If blank below, ask your employer where to file your claim.
Employer Name
Address Telephone
City/Town  State Zip Code
TO EMPLOYEES
THIS NOTICE MUST BE IN TYPE OF NOT LESS THAN TEN 
POINT  BOLD-FACE  AND  POSTED  IN  A  CONSPICUOUS 
PLACE  IN  EACH  PLACE  OF  EMPLOYMENT.  FAILURE  TO 
POST THIS NOTICE WILL SUBJECT THE EMPLOYER TO 
STATUTORY PENALTY (Section 31-279 C.G.S.).
Date Posted:	Any questions as to your rights under the 
law or the obligations of the employer or 
insurance company should be addressed 
to the employer, the insurance company, or 
the Workers’ Compensation Commission  
(1-800-223-9675).	
Revised 10-01-2021