Send this form to: Workers’ Compensation Commission, 21 Oak Street, Hartford, CT 06106-8011 FRI Rev. 3-17-2006 State of Connecticut Workers’ Compensation Commission 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. Employer (Name, Address & Zip) (for WCC use only) Carrier / Administrator Claim # Phone # OSHA Log Case # Jurisdiction Jurisdiction Claim # Employer’s Location Address (if different) SIC Code Report Purpose Code Phone # Claims Administrator (Name, Address & Zip) Phone # FEIN Carrier (Name, Address & Zip) Phone # Policy / Self-Insured # Policy Period (MM/DD/YY) Check, if Self-Insured Employee: Last Name First Name Address (incl. Zip) Middle Name Gender FROM: TO: Date Hired (MM/DD/YY) State of Hire Occupation / Job Title Phone # Male NCCI Class Code Female Date of Birth (MM/DD/YY) Rate of Pay $ ______________________ . ________ per Social Security # Hour Date of Injury / Illness (MM/DD/YY) Town of Injury / Illness Time Employee Began Work Time of Occurrence a.m. Did Injury / Illness occur on Employer’s Premises? p.m. cannot be determined Day Week Bi-Weekly Other Physician / Health Care Provider (Name, Address & Zip) Yes No Type of Injury / Illness a.m. 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) If Fatal, Date of Death (MM/DD/YY) Were Safeguards or Safety Equipment provided? Yes No If provided, were they used? Date Return(ed) to Work (MM/DD/YY) Yes No How Injury / Illness Occurred — Describe the sequence of events, including any objects or substances that directly injured the employee or made the employee ill: Initial Treatment Emergency Care Minor — by Employer Hospitalized More Than 24 Hours Minor — by Clinic / Hospital All equipment, materials, and/or chemicals employee was using when accident or illness exposure occurred: No Medical Treatment Future Major Medical — Lost Time Anticipated Date Administrator Notified (MM/DD/YY) Specific activity and/or work process employee was engaged in when accident or illness exposure occurred: Preparer’s Name & Title Date Prepared (MM/DD/YY) Phone # Contact Name Phone # Cause of Injury Code American LegalNet, Inc. www.FormsWorkflow.com