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State of Connecticut
Workers’ Compensation
Claim Reporting


POLICY
 
The State of Connecticut Workers’ Compensation Program requires that an employee report a work-related injury or illness to his/her employer immediately. For injuries prohibiting the employee from immediately notifying his/her supervisor, the supervisor, on behalf of the injured employee, can directly report the claim.

Employing state agencies must accept all reports of injury from an employee. The employing state agency cannot deny the employee from filing a claim. The Third Party Administrator (TPA) determines issues of compensability and causation, based in part on the information facilitated through the claim reporting process.


TYPES OF NEW WORKERS’ COMPENSATION (WC) CLAIMS
 
All reported claims fall into one of three categories:

   Report Only: An incident that is reported by an employee to the supervisor, but no medical attention is being sought.

   Medical Only: An incident that is reported by an employee to the supervisor with corresponding medical treatment, but the injured employee loses no time from work.

   Lost Time: An incident that is reported by an employee to the supervisor with corresponding medical treatment, and the injured worker loses time from work.

It is important to note that all three categories of reported claims require the use of the DAS Workers’ Compensation Claim Reporting Packet to document the facts of the reported claim.


DAS WC CLAIM PACKET

The following is a general-purpose description of each form within the DAS Claim Packet:

DAS Form 207 - First Report of Injury: This form is used to record information when phoning in the claim to the TPA Injury Intake Center and reviewing the claim in CORE-CT by the human resources (HR) claim-processing unit. The supervisor must provide accurate information on the completed form and to the intake specialist, as it is the basis for the establishment of the claim in CORE-CT.

DAS Form 207-1 - Incident Review Report: This form is completed by the supervisor to record information used for loss control purposes. Form 207-1 identifies the root causes of injury to establish corrective action to reduce the potential for future injury. This form is available in many formats. Work with DAS Workers’ Compensation to design a specific form to meet your agency needs.

WCC Form 1A - Filing Status and Exemption: This Workers’ Compensation Commission form is used to record the injured workers’ federal income tax filing status and number of exemptions for use in establishing the base Workers’ Compensation rate. Either the supervisor or agency WC liaison completes the form, depending on the particular agency claim reporting structure.

DAS Form PER-WC 211 - Concurrent Employment and Third Party Liability: This form is completed to identify if the injured worker has any employment other than the State of Connecticut for potential concurrent employment benefits and to identify any third party negligence-giving rise to the injury.

DAS Form WC-715  - Request for Use of Accrued Leave With Workers' Compensation: This form is used to designate the injured worker's election to utilize or not utilize accrued leave during the interim period and/or to supplement lost wage workers' compensation benefits on an approved workers' compensation claim. Note: General Letter 78 provides agencies with guidance regarding the optional use of accrued leave with workers' compensation claims.  The accrual of sick and vacation leave credits while receiving workers' compensation is governed by C.G.S. 5-251 and is further explained in the DAS Workers' Compensation manual.

DAS Form 208 – Worker Status Report: This form is completed by the initial care or attending physician to record the injured workers diagnosis, course of treatment and work disposition.


COMMUNICATING CLAIM REPORTING RESPONSIBILITIES
 
Communicating general information and specific claim reporting instruction to the workforce is essential if the claim is to be efficiently reported by the injured worker and facilitated by the supervisor.

Section 31-284(f) of the Connecticut General Statutes requires employers to post, in a conspicuous place, a notice of the availability of compensation, in type of not less than ten-point boldface.  It is the requirement of each state agency to post the notice in their human resource "Right to Know" areas.  To complete this statutory requirement click the Workers' Compensation Commission Notice to Employees in a writable PDF version.

The most fundamental piece of claim reporting is communicating the occurrence information to the agency WC office and the TPA. The injured worker and supervisor work together to complete the WC claim packet and reporting process.

Provided below are highlights from both the supervisor and employee communication brochures on WC claim reporting.  Click on each underlined title to link to the actual brochure, suitable for use throughout state government.  Additionally, DAS has worked with select state agencies to develop customized communication brochures.  The Employee Guide to Workers' Compensation Claim Reporting should be incorporated into all new employee orientation sessions and made available to the balance of the workforce.


Supervisors’ Guide to Workers’ Compensation Claim Reporting

This communication piece is for supervisors outlining their responsibilities for recording and facilitating an employee’s claim for WC benefits.

    -
Obtain emergency medical care if needed 
    - Complete claim packet 
    - Phone claim into TPA injury intake center / 1-800-828-2717 
    - Forward completed claim packet to agency WC office 
    - Take corrective action to remove exposure(s) that caused the injury


Prompt and accurate completion of the WC Claim Packet enables (a) the injured employee to pursue his/her claim and (b) the agency and TPA to obtain critical information associated with the reported claim.
 
Employee Guide to Workers’ Compensation Claim Reporting
This communication piece for the workforce is designed to outline general information regarding workers’ compensation, managed care and employee responsibilities associated with their claim. Sections include:
  
    - Injury Notification 
    - Medical Treatment 
    - Return to Work Programs 
    - Health & Safety 
    - Workers’ Compensation Contact Information
 
Distributing this communication to the workforce is fundamental for the effective and consistent administration of any WC program


SUMMARY CLAIM REPORTING PROCEDURE
 
   - Employee immediately reports injury/illness to supervisor 
   - Supervisor must see that the employee receives necessary medical attention: 
        - Emergency medical care if necessary 
        - Direct employee to medical provider directory if emergency medical care is not needed
   - Supervisor must complete DAS WC Claim Packet 
   - Supervisor reports claim to TPA injury reporting hotline 1-800-828-2717 
   - Supervisor forwards completed claim packet to agency workers’ compensation office for CORE-CT processing and review


RECURRENCE CLAIM REPORTING PROCEDURE
 
An injured employee must immediately report a recurrence to his/her supervisor and human resources department, providing as much of the following information as possible:
 
  - Original date of Injury
  - Original Claim Number
  - Details of the recurrence
  - What medical facility he/she is treated at for the recurrence
  - Submit the medical disposition supporting the recurrence

The supervisor or human resources department, depending on the agency reporting structure, will phone the recurrence information to the TPA by dialing 860-256-3400 then press 7, that will take you to the recurrence desk.


FEDERAL INJURY REPORTING OSHA 300 Log

OSHA requires all covered employers with more than ten employees to keep a log of work-related injuries and illnesses and to post a summary of that information each year from February 1 through April 30.  OSHA has revised the OSHA 300 Log and OSHA 300A Summary for 2004.  Employers must use the revised forms for recordable injuries and illnesses occurring on or after January 1, 2004.  An injury or illness meets the general criteria, and is recordable if it results in any of the following: death, days away from work, restricted work or transfer to another job, medical treatment beyond first aid, or loss of consciousness.  You must record a case if it involves a significant injury or illness diagnosed by a physician or other licensed health care professional, even if it does not result in death, days away from work, restricted work or job transfer, medical treatment beyond first aid, or loss of consciousness.  An injury or illness may be "compensable" under workers' compensation and not "recordable" under OSHA.
OSHA logs can be produced either manually or through Core-CT.


Click here for the Federal OSHA requirements and sample log.

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