Follow the steps to complete the form accurately and efficiently.

1. Click 'Get Form' button to retrieve the CT Workers Compensation Commission Form 1-A and access it in your preferred online format.
2. Begin by entering the WCC file number in the designated field to reference your case. This is typically provided to you after filing initial paperwork.
3. Fill in the 'Filing Status and Exemption' section. Provide the date of injury, ensuring it reflects the incident accurately. Next, indicate your federal tax filing status by selecting from the provided options: Single, Head of Household, Married filing jointly, or Married filing separately. This selection must align with your tax return for the relevant date.
4. Enter the number of exemptions you claimed on your tax return as of the date of injury. This includes yourself in the count.
5. Respond to the FICA withholding question by selecting 'Yes' or 'No'. If you select 'No', be aware that the insurer will need to manually calculate the weekly benefit rate.
6. Check all applicable boxes concerning age and legal blindness which pertain to you or your spouse.
7. In the exemption list section, provide the names, dates of birth, and relationships for all individuals included in your exemption count from step 4, starting with yourself.
8. For concurrent employment, if applicable, provide the names and addresses of any other employers you were working for on the date of the injury. Include the date of hire for each employer.
9. Finally, ensure all information is accurate to the best of your knowledge. Sign and date the form in the designated signature area, whether you are the injured worker or a representative.

Complete your CT Workers Compensation Commission Form 1-A online today to ensure you receive the benefits you deserve.