Free FORM - Connecticut

State of Connecticut Workers' Compensation Commission
Please TYPE or PRINT IN INK

1A
Date filed in District
(for WCC use only)

Filing Status and Exemption
This form must be executed in every case of compensable disability for injuries occurring ON OR AFTER October 1, 1991, and must be completed in its entirety.

EMPLOYEE
Name Address City/Town State Zip Code Soc. Sec.# (optional)

FILING STATUS AND EXEMPTIONS -- In order to determine your weekly benefit rate, as per
Sec. 31-310 C.G.S.,we need the following information: 1. Select your Federal tax filing status based upon your ACTUAL filing status as of the date of injury, listed at right:
(Must match your tax return, as if you were filing with the IRS on the date of your injury.)

Single

Head of Household

Married filing jointly

Married filing separately

2. Number of exemptions (including yourself) as of the date of injury listed at right = 3. FICA withheld for the above-named employee? .............................. 4. Check all appropriate boxes: Employee 65 years of age or older Employee legally blind Spouse 65 years of age or older Spouse legally blind YES ................. NO -- If NO, insurer must manually calculate weekly benefit rate.

5. List name (yourself first), date of birth, and relationship to you for all exemptions included in question #2, above: Name Date of Birth Relationship SELF

CONCURRENT EMPLOYMENT -- To be certain you receive all the benefits to which you are entitled, provide the following information
if you were working for more than one employer on the date of injury indicated above: Name of Employer Address Date of Hire

NOTE: Wage information for each concurrent employer must be supplied by the claimant.

SIGNATURE OF INJURED WORKER OR REPRESENTATIVE
I hereby attest that the above information is correct to the best of my knowledge.

Employee's Signature

Date

Rev. 10-3-2006

WCC File #

DATE OF INJURY: