DECEASED222S INJURYDate of InjuryDate of DeathTown of InjuryDescribe employee222s Injury/Illness and its relationship to cause of death: � Check, if an Occupational Disease or a Repetitive Trauma � Check, if decedent had MORE THAN ONE Employer on Date of Injury Notice is hereby given that the injured worker, while in the employ of the employer, sustained injuries arising out of and in the course of his/her employment and died as a result of such work-related injury or illness in the manner described below.(for WCC use only) 30D Rev. 01-31-2018DECEASED EMPLOYEEDECEASED222S EMPLOYEREmployerAddress Town � State Zip Code � Tel.# SIGNATURE OF DEPENDENT OR REPRESENTATIVESignatureDatePrint name & address below, if other than dependent:NameName of FirmAddress Town � State Zip Code � Tel.# DEPENDENTNameD.O.B.Check, if a Minor � (under 18 yrs. of age)Relationship to deceased employeeAddress Town � State Zip Code � Tel.# * � Dependents of persons employed by the State of Connecticut must serve the employer by serving this notice upon the Commissioner of Administrative Services, � 450 Columbus Boulevard, Hartford, CT 06103. * � Dependents of persons employed by a municipality must serve the employer by serving this notice upon the town clerk of the municipality in which the employee � was employed. � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � WARNING: � 223without American LegalNet, Inc. www.FormsWorkFlow.com There is a statute of limitations for filing a workers222 compensation claim for death benefits. If death results within two years from the date of the accident or first manifestation of a symptom of the occupational disease, a claim may be made within the two year period, or within one year from the date of death, whichever is later. (Sec. 31-294c) Directions for Completing the 30D Claim Form 1. In the box marked 223DEPENDENT224 226 type or neatly print the name, date of birth, and address of the dependent who is filing the claim on behalf of the deceased worker. Remember to check the box, if the dependent is a minor (under the age of 18). Identify the dependent222s relationship to the deceased worker. 2. In the box marked 223DECEASED EMPLOYEE224 226 type or neatly print the name of the deceased worker. Also fill in the deceased worker222s date of birth. 3. In the box marked 223DECEASED222S EMPLOYER224 226 type or neatly print the name of the deceased worker222s employer. (This means the name of the organization the decedent worked for, not the boss or supervisor.) 4. In the 223DECEASED222s INJURY224 box 226 type or neatly print the date of the deceased worker222s injury, or the date of the 1st manifestation of their occupational illness. Type the date of death and the town in which the injury actually took place. (Note: This will not necessarily be the same location as the employer222s business address.) Briefly describe the employee222s injury/illness and explain how it was related to their death. Also: Check the box if the employee died from an Occupational Disease, or a Repetitive Trauma. Check the box if the employee worked for MORE THAN ONE employer on the Date of Injury. 5. In the 223SIGNATURE OF DEPENDENT OR REPRESENTATIVE224 box 226 sign your name and fill in the date of your signature. If you are NOT the dependent for whom benefits are being claimed, then sign your name, and fill in the date of your signature. Then print your name and the name (if any) of your firm, as well as the address and telephone number. American LegalNet, Inc. www.FormsWorkFlow.com Directions for Filing the 30D Claim Form 1. Make two (2) extra copies of the completed 30D Form. 2. Send the original 30D to the deceased worker222s employer by Certified or Registered mail, requesting a return receipt. The claim may also be delivered in person if the employer acknowledges receipt of the claim in writing. A 30D Form filed on behalf of a dependent of a State employee must be delivered to the Commissioner of Administrative Services, 450 Columbus Boulevard, Hartford, CT 06103 and NOT to the particular office where the deceased worker was employed. A 30D Form filed on behalf of a dependent of a Municipal employee must be delivered to the town clerk of the municipality in which the deceased worker was employed. A 30D Form filed on behalf of a dependent of an employee (other than a State or municipal employee), who pursuant to statute has posted the location where claims for compensation are to be filed, must be filed at that location, by certified mail. 3. Send a copy of the 30D to the appropriate Workers222 Compensation Commission District Office by Certified or Registered mail, requesting a return receipt, or deliver in person. The District Office is determined by the town in which the deceased employee was injured or in which they suffered their occupational illness. Refer to the Connecticut map provided with this form for the number and address of the appropriate Compensation District. 4. Keep the remaining copy of the 30D for your own file. American LegalNet, Inc. www.FormsWorkFlow.com 12345678State of ConnecticutWorkers222 Compensation Districts[effective 5-1-06] American LegalNet, Inc. www.FormsWorkFlow.com Work ers222 Com pen sa tion Commission Dis trict Of ficesDis trict 1 227 Hart ford 999 Asy lum Ave nueHart ford, CT 06105Phone: (860) 566- 4154Fax: (860) 566-6137Dis trict 2 227 Nor wich 55 Main StreetNor wich, CT 06360Phone: (860) 823- 3900Fax: (860) 823-1725Dis trict 3 227 New Ha ven 700 State StreetNew Ha ven, CT 06511- 6500Phone: (203) 789- 7512Fax: (203) 789-7168Dis trict 4 227 Bridge port 350 Fair field Ave nueBridge port, CT 06604Phone: (203) 382- 5600Fax: (203) 335-8760Dis trict 5 227 Wa ter bury 55 West Main StreetWa ter bury, CT 06702Phone: (203) 596- 4207Fax: (203) 805-6501Dis trict 6 227 New Brit ain 233 Main StreetNew Brit ain, CT 06051Phone: (860) 827- 7180Fax: (860) 827-7913Dis trict 7 227 Stam ford 111 High Ridge RoadStam ford, CT 06905Phone: (203) 325- 3881Fax: (203) 967-7264Dis trict 8 227 Mid dle town 90 Court StreetMid dle town, CT 06457Phone: (860) 344- 7453Fax: (860) 344-7487 American LegalNet, Inc. www.FormsWorkFlow.com