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Ct first report injury form 2026
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- Click ‘Get Form’ to open the ct first report injury form in the editor.
- Begin by entering the Agency Location Code and Division/Region in the designated fields.
- Input the employee's Social Security Number (SSN) and Employee Number for identification purposes.
- Fill in the Name of the Injured Worker, including First, Last, and Middle Initial.
- Complete the Home Address section with City or Town, State, and Zip code.
- Provide the Home Telephone number and Date of Birth of the injured worker.
- Indicate the Sex, Job Classification, Date of Hire, Date of Incident, Time of Incident, and Time Employer Notified.
- Answer whether the Injury was Fatal and provide relevant dates if applicable.
- Describe how the Injury Occurred and specify the Type of Injury along with Body Part(s) Affected.
- Confirm if the Injury Occurred on Employer Premises and if Medical Treatment is being sought.
- List any Witnesses to the Injury along with their contact information.
- Complete Supervisor information including Name, Title, Work Phone, and Signature for finalization.
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What is the employers first report of injury in CT?
The Employers First Report of Occupational Injury or Illness form is to be completed by an employer or its workers compensation insurance carrier to notify the Workers Compensation Commission of occupational injuries or illnesses that result in incapacity for one day or more.
What is WC 207 form?
Supervisors are responsible for completing the DAS WC-207 form when an employee reports an injury. The information documented on this form is used to determine the entitlement benefits.
What is form 43 in Connecticut?
FORM: 43 - Notice to Administrative Law Judge and Employee of Intention to Contest Employees Right to Compensation Benefits.
What is a first injury report?
The Employers First Report of Injury or Illness provides information on the claimant, employer, insurance carrier and medical practitioner necessary to begin the claims process. Details of the claimants employment and circumstances surrounding the injury or illness are also requested.
Who may follow the first report of injury?
The FROI serves as the official notification to the employer, insurance carrier, and relevant regulatory authorities about the occurrence of a work-related injury or illness and triggers the investigation, evaluation, and administration of the workers compensation claim.
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People also ask
What if my employer lied about the first report of injury?
If the employer is lying to the carrier, saying that the employee did not report it when he did, in fact, report it, then that could be considered Workers Compensation fraud, which is a crime. It probably will not mean any extra benefits for the employee.
How long does an employee have to report an injury to their employer in CT?
The State of Connecticut Workers Compensation Program requires that an employee report a work-related injury or illness to his/her employer immediately.
workers compensation case lookup
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