"Employer's First Report of Occupational Injury or Illness" - Connecticut

Employer's First Report of Occupational Injury or Illness is a legal document that was released by the Connecticut Workers' Compensation Commission - a government authority operating within Connecticut.

Form Details:

  • Released on July 13, 2009;
  • The latest edition currently provided by the Connecticut Workers' Compensation Commission;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut Workers' Compensation Commission.

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FRI
State of Connecticut
Workers’ Compensation Commission
Send this form to: Workers’ Compensation Commission, 21 Oak Street, Hartford, CT 06106-8011
Date filed in Chairman’s Office
Employer’s First Report of Occupational Injury or Illness
File pursuant to C.G.S. § 31-316 for injuries that result in INCAPACITY FOR ONE DAY OR MORE. Please TYPE or PRINT IN INK.
(for WCC use only)
Carrier / Administrator Claim #
OSHA Log Case #
Report Purpose Code
Employer
(Name, Address & Zip)
Phone #
Jurisdiction
Jurisdiction Claim #
Employer’s Location Address
(if different)
Phone #
SIC Code
FEIN
Carrier
Claims Administrator
(Name, Address & Zip)
(Name, Address & Zip)
Phone #
Phone #
Policy / Self-Insured #
Policy Period
(MM/DD/YY)
q
Check, if Self-Insured
FROM:
TO:
Employee: Last Name
First Name
Middle Name
Date Hired
State of Hire
(MM/DD/YY)
Gender
Occupation / Job Title
D.O.B.
Phone #
(required)
q
Male
Address
(incl. Zip)
NCCI Class Code
q
Rate of Pay $ ______________________ . ________ per
Female
q
q
q
q
q
Hour
Day
Week
Bi-Weekly
Other
Date of Injury / Illness
Town of Injury / Illness
Physician / Health Care Provider
(MM/DD/YY)
(Name, Address & Zip)
Time Employee Began Work
Did Injury / Illness occur
q
a.m.
q
q
on Employer’s Premises?
Yes
No
q
p.m.
Time of Occurrence
Type of Injury / Illness
q
cannot be determined
q
a.m.
q
p.m.
Part of Body Affected
Date Employer Notified
(MM/DD/YY)
Hospital
(Name, Address & Zip)
Type of Injury / Illness Code
Date Disability Began
(MM/DD/YY)
Part of Body Affected Code
Date Last Worked
(MM/DD/YY)
Were Safeguards or Safety
q
q
Yes
No
Equipment provided?
Date Return(ed) to Work
(MM/DD/YY)
q
q
Yes
No
If provided, were they used?
Initial Treatment
If Fatal, Date of Death
How Injury / Illness Occurred — Describe the sequence
(MM/DD/YY)
q
q
of events, including any objects or substances that
No Medical Treatment
Emergency Care
directly injured the employee or made the employee ill:
q
q
All equipment, materials, and/or chemicals employee
Minor — by Employer
Hospitalized More Than 24 Hours
was using when accident or illness exposure occurred:
q
q
Minor — by Clinic / Hospital
Future Major Medical — Lost Time
Anticipated
Date Administrator Notified
Date Prepared
(MM/DD/YY)
(MM/DD/YY)
Specific activity and/or work process employee was
engaged in when accident or illness exposure occurred:
Preparer’s Name & Title
Phone #
Contact Name
Cause of Injury Code
Phone #
FRI
State of Connecticut
Workers’ Compensation Commission
Send this form to: Workers’ Compensation Commission, 21 Oak Street, Hartford, CT 06106-8011
Date filed in Chairman’s Office
Employer’s First Report of Occupational Injury or Illness
File pursuant to C.G.S. § 31-316 for injuries that result in INCAPACITY FOR ONE DAY OR MORE. Please TYPE or PRINT IN INK.
(for WCC use only)
Carrier / Administrator Claim #
OSHA Log Case #
Report Purpose Code
Employer
(Name, Address & Zip)
Phone #
Jurisdiction
Jurisdiction Claim #
Employer’s Location Address
(if different)
Phone #
SIC Code
FEIN
Carrier
Claims Administrator
(Name, Address & Zip)
(Name, Address & Zip)
Phone #
Phone #
Policy / Self-Insured #
Policy Period
(MM/DD/YY)
q
Check, if Self-Insured
FROM:
TO:
Employee: Last Name
First Name
Middle Name
Date Hired
State of Hire
(MM/DD/YY)
Gender
Occupation / Job Title
D.O.B.
Phone #
(required)
q
Male
Address
(incl. Zip)
NCCI Class Code
q
Rate of Pay $ ______________________ . ________ per
Female
q
q
q
q
q
Hour
Day
Week
Bi-Weekly
Other
Date of Injury / Illness
Town of Injury / Illness
Physician / Health Care Provider
(MM/DD/YY)
(Name, Address & Zip)
Time Employee Began Work
Did Injury / Illness occur
q
a.m.
q
q
on Employer’s Premises?
Yes
No
q
p.m.
Time of Occurrence
Type of Injury / Illness
q
cannot be determined
q
a.m.
q
p.m.
Part of Body Affected
Date Employer Notified
(MM/DD/YY)
Hospital
(Name, Address & Zip)
Type of Injury / Illness Code
Date Disability Began
(MM/DD/YY)
Part of Body Affected Code
Date Last Worked
(MM/DD/YY)
Were Safeguards or Safety
q
q
Yes
No
Equipment provided?
Date Return(ed) to Work
(MM/DD/YY)
q
q
Yes
No
If provided, were they used?
Initial Treatment
If Fatal, Date of Death
How Injury / Illness Occurred — Describe the sequence
(MM/DD/YY)
q
q
of events, including any objects or substances that
No Medical Treatment
Emergency Care
directly injured the employee or made the employee ill:
q
q
All equipment, materials, and/or chemicals employee
Minor — by Employer
Hospitalized More Than 24 Hours
was using when accident or illness exposure occurred:
q
q
Minor — by Clinic / Hospital
Future Major Medical — Lost Time
Anticipated
Date Administrator Notified
Date Prepared
(MM/DD/YY)
(MM/DD/YY)
Specific activity and/or work process employee was
engaged in when accident or illness exposure occurred:
Preparer’s Name & Title
Phone #
Contact Name
Cause of Injury Code
Phone #