Free FORM - Connecticut

State of Connecticut Workers' Compensation Commission
Send this form to: Workers' Compensation Commission, 21 Oak Street, Hartford, CT 06106-8011

FRI
Date filed in Chairman's Office (for WCC use only) OSHA Log Case # Jurisdiction Claim # Report Purpose Code Phone #

Employer's First Report of Occupational Injury or Illness
File pursuant to C.G.S. § 31-316 for injuries that result in INCAPACITY FOR ONE DAY OR MORE. Please TYPE or PRINT IN INK.
Employer (Name, Address & Zip) Phone # Carrier / Administrator Claim # Jurisdiction Employer's Location Address (if different)

SIC Code

FEIN

Carrier (Name, Address & Zip)

Phone #

Claims Administrator (Name, Address & Zip)

Rev. 3-17-2006
Phone #

Policy / Self-Insured # Check, if Self-Insured Employee: Last Name Address (incl. Zip) First Name Middle Name Gender

Policy Period (MM/DD/YY) FROM: Date Hired (MM/DD/YY) Occupation / Job Title Male NCCI Class Code Female Rate of Pay $ ______________________ . ________ per Hour Day Week Bi-Weekly Other TO: State of Hire

Phone #

Date of Birth (MM/DD/YY)

Social Security #

Date of Injury / Illness (MM/DD/YY)

Town of Injury / Illness

Physician / Health Care Provider (Name, Address & Zip)

Time Employee Began Work

a.m. Did Injury / Illness occur on Employer's Premises? p.m. cannot be determined Type of Injury / Illness

Yes

No

Time of Occurrence

a.m. p.m. Part of Body Affected Date Employer Notified (MM/DD/YY) Type of Injury / Illness Code Date Disability Began (MM/DD/YY) Part of Body Affected Code Date Last Worked (MM/DD/YY) Were Safeguards or Safety Equipment provided? If provided, were they used? If Fatal, Date of Death (MM/DD/YY) Hospital (Name, Address & Zip)

Date Return(ed) to Work (MM/DD/YY)

Yes Yes

No No Initial Treatment No Medical Treatment Minor -- by Employer Minor -- by Clinic / Hospital Emergency Care Hospitalized More Than 24 Hours Future Major Medical -- Lost Time Anticipated Date Prepared (MM/DD/YY)

How Injury / Illness Occurred -- Describe the sequence of events, including any objects or substances that directly injured the employee or made the employee ill:

All equipment, materials, and/or chemicals employee was using when accident or illness exposure occurred:

Specific activity and/or work process employee was engaged in when accident or illness exposure occurred:

Date Administrator Notified (MM/DD/YY)

Preparer's Name & Title

Phone #

Contact Name Phone # Cause of Injury Code