Workers' Compensation Forms - Page 5

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Commonly Asked Questions about Workers' Compensation Forms

Form CA-7 should be submitted by an injured worker (IW) every two weeks while disabled and in a LWOP status, unless the IW has been placed on the periodic roll. For traumatic injury cases, Form CA-7 should be completed before the end of the COP period, if disability will continue.
Injured postal workers are required to fill in form CA-17, which is a form which outlines information from a doctor forbidding an injured federal employee from carrying out certain activities due to their inherently physically taxing nature.
QIW means an employee who, as the result of his/her injury, whether or not combined with the effects of any other medical condition, cannot return to his/her usual customary occupation or job at time of injury.
The CA-17 was designed to provide the doctor with an accurate description of the physical work requirements of the injured letter carrier. The CA-17 is a legal document that determines both an injured workers medical restrictions and entitlement to wage-loss compensation benefits.
To file a workers compensation claim in Connecticut, you must complete Form 30C, send the original to your employer, and send a copy to the Workers Compensation Commission District Office.
Form CA-7 should be submitted by an injured worker (IW) every two weeks while disabled and in a LWOP status, unless the IW has been placed on the periodic roll.
The Employers Report of Occupational Injury or Illness (Form 5020). Every employer is required to file a complete report of every occupational injury or illness to each employee which results in lost time beyond the date of injury or illness or which requires medical treatment beyond first aid*.
As a general rule, TD pays two-thirds of the gross (pre-tax) wages you lose while you are recovering from a job injury. However, you cannot receive more than the maximum weekly amount set by law.