Understanding the Workers' Compensation Affidavit – Simsbury, Conn. (Gen. Stat. §31‑286b) Form

What Is the Workers' Compensation Affidavit?

The Workers' Compensation Affidavit is a sworn statement used in Connecticut to provide evidence of an injury or illness that may be covered by the state's workers' compensation system. It is required for employees who believe they have a claim but have not yet filed a formal claim with the Department of Labor and Industry.

Legal Basis: Gen. Stat. §31‑286b

Connecticut General Statutes §31‑286b mandates that any employee who has been injured on the job must submit an affidavit to the Department of Labor and Industry within 30 days of the injury. Failure to comply can result in a denial of benefits or delayed processing.

When and How to File

Employees should file the affidavit within 30 days of the date of injury or onset of illness. The form can be submitted electronically via the Department's online portal or in paper form sent by mail. If the injury occurred before the employee's start date, the 30‑day clock begins on the date of the injury.

Key Sections of the Form

• Personal Information – Name, address, employee ID, and employer details.
• Injury Description – Date, location, and circumstances of the injury.
• Medical Treatment – Details of any medical care received, including provider names and dates.
• Witness Statements – Names and contact information of any witnesses.
• Signature and Date – The employee's sworn statement, notarized if required.

Common Mistakes to Avoid

1. Late Submission – Missing the 30‑day deadline can jeopardize benefits.

2. Incomplete Information – Omitting key details such as the exact date or location of the injury.

3. Failure to Provide Medical Records – The affidavit must be supported by medical documentation.

What Happens After Filing?

Once the Department receives the affidavit, it will review the information and may request additional evidence. If the claim is accepted, the employee will receive workers' compensation benefits, including medical treatment and wage replacement as applicable.

Important Resources

• Connecticut Department of Labor and Industry

• Download the Affidavit Form (PDF)

FAQ

• Can I file after the 30‑day period? Late filings are possible but may delay benefits.
• Do I need a lawyer? Not required, but legal counsel can help ensure accuracy.