Free FORM - Connecticut

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 31-294b 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 COMPANY or SELF-INSURANCE ADMINISTRATOR is: Name Address City/Town State Approved Medical Care Plan Yes Telephone Zip Code No

The State of Connecticut Workers' Compensation Commission office for this workplace is located at: Address City/Town State Telephone 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 (1-800-223-9675). THIS NOTICE MUST BE IN TYPE OF NOT LESS THAN TEN POINT BOLD-FACE AND POSTED IN A CONSPICUOUS PLACE IN EACH PLACE OF EMPLOYMENT. FAILURE TO POST THIS NOTICE WILL SUBJECT THE EMPLOYER TO STATUTORY PENALTY (Section 31-279 C.G.S.). Date Posted
Rev. 8-31-2004