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Get Form: 1a - Filing Status And Exemption. Connecticut Workers' Compensation Commission Agency Forms
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How to fill out the FORM: 1A - Filing Status And Exemption. Connecticut Workers' Compensation Commission Agency Forms online
Filling out the FORM: 1A - Filing Status And Exemption is an essential step for individuals seeking compensation for work-related injuries in Connecticut. This guide will provide you with clear, step-by-step instructions to help you accurately complete the form online.
Follow the steps to successfully complete your filing status and exemption form.
- Press the ‘Get Form’ button to access the FORM: 1A and open it for editing.
- Enter your personal information in the fields provided. This includes your name, social security number (optional), address, city or town, state, and zip code. Ensure that this information is complete and accurate.
- In the ‘Filing Status and Exemptions’ section, select your federal tax filing status as of the date of injury. Choose one option: Single, Head of Household, Married filing jointly, or Married filing separately.
- Indicate the number of exemptions you are claiming as of the date of injury, including yourself.
- Answer whether FICA was withheld for the employee. Select ‘Yes’ or ‘No’. If ‘No’ is selected, be aware that the insurer must manually calculate the weekly benefit rate.
- Check all applicable boxes related to age or blindness status, including options for the employee or spouse.
- In the provided section, list the name, date of birth, and relationship of all exemptions you included previously, starting with yourself.
- If you had concurrent employment on the date of injury, provide details about your employer, including their name, address, and date of hire. Remember that wage information for each employer must be supplied by the claimant.
- Finally, sign and date the form in the signature section to attest that the information you provided is accurate to the best of your knowledge.
- Once completed, save your changes. You can also choose to download, print, or share the form as needed.
Take action now and complete your FORM: 1A online to ensure you receive the benefits you are entitled to.
You may also receive up to 208 weeks of compensation (at the same rate) if your injury left you with permanent disfigurement or significant scarring on your face, head, neck, or any part of your body that would hinder your ability to find work. (Conn. Gen. Stat.
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