State of Connecticut Workers Compensation Commission
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1 State of Connecticut Workers Compensation Commission Notice to Employees Workers Compensation Act Chapter 568 of the Connecticut General Statutes (the Workers Compensation Act) requires your employer, to provide benefits to you in case of injury or occupational disease in the course of employment. Section b of the Workers Compensation Act states: Any employee who has sustained an injury in the course of his employment shall immediately report the injury to his employer, or some person representing his employer. If the employee fails to report the injury immediately, the commissioner may reduce the award of compensation proportionately to any prejudice that he finds the employer has sustained by reason of the failure, provided the burden of proof with respect to such prejudice shall rest upon the employer. Such an injury report by the employee is NOT an official written notice of claim for workers compensation benefits. (The Form 30C is necessary to satisfy this requirement.) The INSURANCE COMPAN or SELF-INSURANCE ADMINISTRATOR is: Name Address Telephone City/Town State Zip Code Approved Medical Care Plan es No The State of Connecticut Workers Compensation Commission office for this workplace is located at: Address Telephone City/Town State Zip Code Any questions as to your rights under the law or the obligations of the employer or insurance company should be addressed to the employer, the insurance company or the Workers Compensation Commission ( ). THIS NOTICE MUST BE IN TPE OF NOT LESS THAN TEN POINT BOLD-FACE AND POSTED IN A CONSPICUOUS PLACE IN EACH PLACE OF EMPLOMENT. FAILURE TO POST THIS NOTICE WILL SUBJECT THE EMPLOER TO STATUTOR PENALT (Section C.G.S.). Date Posted Rev
2 State of Connecticut Workers Compensation Commission Send this form to: Workers Compensation Commission, 21 Oak Street, Hartford, CT Employer s First Report of Occupational Injury or Illness File pursuant to C.G.S for injuries that result in INCAPACIT FOR ONE DA OR MORE. Please TPE or PRINT IN INK. Rev Date filed in Chairman s Office (for WCC use only) FRI Employer (Name, Address & Zip) Carrier / Administrator Claim # OSHA Log Case # Report Purpose Code Jurisdiction Jurisdiction Claim # Employer s Location Address (if different) SIC Code FEIN Carrier (Name, Address & Zip) Claims Administrator (Name, Address & Zip) Policy / Self-Insured # q Check, if Self-Insured Policy Period (MM/DD/) FROM: TO: Employee: Last Name First Name Middle Name Gender Date Hired (MM/DD/) State of Hire D.O.B. (required) Address (incl. Zip) q Male q Female Occupation / Job Title Rate of Pay $. per NCCI Class Code q Hour q Day q Week q Bi-Weekly q Other Date of Injury / Illness (MM/DD/) Town of Injury / Illness Physician / Health Care Provider (Name, Address & Zip) Time Employee Began Work Time of Occurrence Date Employer Notified (MM/DD/) q a.m. q p.m. q cannot be determined q a.m. q p.m. Did Injury / Illness occur on Employer s Premises? q es q No Type of Injury / Illness Part of Body Affected Hospital (Name, Address & Zip) Type of Injury / Illness Code Date Disability Began (MM/DD/) Part of Body Affected Code Date Last Worked (MM/DD/) Date Return(ed) to Work (MM/DD/) Were Safeguards or Safety Equipment provided? q es q No If Fatal, Date of Death (MM/DD/) If provided, were they used? q es q No How Injury / Illness Occurred Describe the sequence of events, including any objects or substances that directly injured the employee or made the employee ill: Initial Treatment q No Medical Treatment q Emergency Care All equipment, materials, and/or chemicals employee was using when accident or illness exposure occurred: q Minor by Employer q Hospitalized More Than 24 Hours q Minor by Clinic / Hospital q Future Major Medical Lost Time Anticipated Specific activity and/or work process employee was engaged in when accident or illness exposure occurred: Date Administrator Notified (MM/DD/) Date Prepared (MM/DD/) Preparer s Name & Title Contact Name Cause of Injury Code
3 State of Connecticut Workers Compensation Commission Notice of Claim for Compensation (Employee to Commissioner and to Employer) : ; < : = < > : A B 5 = C D D 6 7 < : 9 < = : 8 9 : 9 :? 6 E > : A F 7 = > E? 6 7 : = G 9 ; ; = E? =? H I JK L M K N O I P Q R I S T U N T U T U V 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 as follows, and makes claim 30C ' ( ) * +,, -. / ) INJURED WORKER & " W W W INJUR # X! "! # $ % & & $ $ " EMPLOER $ " X SIGNATURE OF INJURED WORKER OR REPRESENTATIVE X ^ [ & " $ " \ ] $ X & & " & \ & " _ " X ` a = : 7 9 E 7 = ; < b 9 A A B 5 = c B > B = 9 8 D 9 E E = G B 6 G F B ; F 7 B > b = : d = B 5 = = ; < b 9 A = A 7 = : d 6 E e B E 9 B 6 G = F < 9 E B 5 = D 9 ; ; E = : 9 8 f? ; 6 E 6 7 B : > B 6 d = c = : d 6 G = 7 H g h i j k j l m n o p q r s t q
4 State of Connecticut Workers Compensation Districts [effective ]
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6 Work ers Com pen sa tion Commission Dis trict Of fices Dis trict 1 Hart ford 999 Asy lum Ave nue Hart ford, CT Phone: (860) Fax: (860) Dis trict 5 Wa ter bury 55 West Main Street Wa ter bury, CT Phone: (203) Fax: (203) Dis trict 2 Nor wich 55 Main Street Nor wich, CT Phone: (860) Fax: (860) Dis trict 6 New Brit ain 233 Main Street New Brit ain, CT Phone: (860) Fax: (860) Dis trict 3 New Ha ven 700 State Street New Ha ven, CT Phone: (203) Fax: (203) Dis trict 7 Stam ford 111 High Ridge Road Stam ford, CT Phone: (203) Fax: (203) Dis trict 4 Bridge port 350 Fair field Ave nue Bridge port, CT Phone: (203) Fax: (203) Dis trict 8 Mid dle town 90 Court Street Mid dle town, CT Phone: (860) Fax: (860)
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