Connecticut Workers’ Comp Forms & Resources
Connecticut Required Postings and Forms
Please print and post the following notices, both in English and Spanish, in a conspicuous location frequented by employees, such as the break room, lunch room or time clock. If you have multiple business locations, be sure to post the notices at each location.
This notice must be printed on 8.5” X 14” gold or yellow paper, include the complete employer/insurer information in the lower left corner where indicated and posted in a conspicuous location at each work site or location in accordance with COMAR 14.09.01.02 and 14.09.01.03. Laser printer or clear photocopier versions are recommended for printed durability and legibility.
The following forms need to be completed and submitted to EMPLOYERS when a work-related injury occurs:
- First Report of Injury or Illness (FROI). (Note: This is an online form.) This 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. As soon as you have been notified of a work-related injury, please fill out this form and submit it to the following address: Workers’ Compensation Commission, 21 Oak Street Hartford, CT 06106-8011.
- First Fill Form. This form provides your employees with basic information about our Pharmacy Benefit Program, including such things as the phone number to call to locate a First Fill participating pharmacy. When your employee becomes injured, please print and complete this form and provide it to your injured employee. Your employee will need to provide this completed form along with the prescription for his/her work-related injury or illness to the pharmacist. Using this form will help enable quick authorization for your employee’s initial medication and ensure that the initial prescription is provided at no cost to the injured employee.
This form must be completed and submitted in duplicate within seven days from notice of an accident. Fatalities must be reported within 24 hours.
- Wage Statement. This form enables us to calculate the correct compensation owed to an injured employee. Please complete the form and submit it to EMPLOYERS® within five days after your knowledge of any accident that has caused your employee to be disabled for more than seven scheduled calendar work days.
- Accident Investigation Report. This basic accident form should be completed by the employee’s supervisor/manager as soon as possible after the accident. Please send the report to the following EMPLOYERS address as soon as it has been completed by the supervisor/manager: EMPLOYERS Claim Department, P.O. Box 32036, Lakeland, FL 33802-2036.
The adjusting of the claims in Connecticut are handled by Broadspire. Once a claim is reported to EMPLOYERS, the report will be sent to Broadspire for assignment.
More Connecticut Workers’ Comp Resources
- Off-Site Transitional Duty Program - Helping Your Injured Employees Get Back to Work
A successful transition back to work relies on the collaborative efforts of the manager/supervisor, the injured employee and their adjuster. As a manager/supervisor, learn what you can do to help facilitate a successful return to work.