How To

TYPES OF NEW WORKERS’ COMPENSATION (WC) CLAIMS

All reported claims fall into one of three categories:

Report Only: An incident that is reported by an employee to the supervisor, but no medical attention is being sought.

Medical Only: An incident that is reported by an employee to the supervisor with corresponding medical treatment, but the injured employee loses no time from work.

Lost Time: An incident that is reported by an employee to the supervisor with corresponding medical treatment, and the injured worker loses time from work.

DAS Workers’ Compensation Report Packet

It is important to note that all three categories of reported claims require the use of the DAS Workers’ Compensation Claim Reporting Packet to document the facts of the reported claim.

The following is a general-purpose description of each form within the DAS Claim Packet:

DAS Form 207 - First Report of Injury: This form is used to record information when phoning in the claim to the TPA Injury Intake Center and reviewing the claim in CORE-CT by the human resources (HR) claim-processing unit. The supervisor must provide accurate information on the completed form and to the intake specialist, as it is the basis for the establishment of the claim in CORE-CT.

DAS Form 207-1 - Incident Review Report: This form is completed by the supervisor to record information used for loss control purposes. Form 207-1 identifies the root causes of injury to establish corrective action to reduce the potential for future injury. This form is available in many formats. Work with DAS Workers’ Compensation to design a specific form to meet your agency needs.

WCC Form 1A - Filing Status and Exemption: This Workers’ Compensation Commission form is used to record the injured workers’ federal income tax filing status and number of exemptions for use in establishing the base Workers’ Compensation rate. Either the supervisor or agency WC liaison completes the form, depending on the particular agency claim reporting structure.

DAS Form PER-WC 211 - Concurrent Employment and Third Party Liability: This form is completed to identify if the injured worker has any employment other than the State of Connecticut for potential concurrent employment benefits and to identify any third-party negligence-giving rise to the injury.

DAS Form WC-715  - Request for Use of Accrued Leave With Workers' Compensation: This form is used to designate the injured worker's election to utilize or not utilize accrued leave during the interim period and/or to supplement lost wage workers' compensation benefits on an approved workers' compensation claim. Note: General Letter 78 provides agencies with guidance regarding the optional use of accrued leave with workers' compensation claims.  The accrual of sick and vacation leave credits while receiving workers' compensation is governed by C.G.S. 5-251 and is further explained in the DAS Workers' Compensation manual.

DAS Form 208 – Worker Status Report: This form is completed by the initial care or attending physician to record the injured workers diagnosis, course of treatment and work disposition.

SUMMARY CLAIM REPORTING PROCEDURE

1. Employee immediately reports injury/illness to supervisor
2. Supervisor must see that the employee receives the necessary medical attention
   - Emergency medical care if necessary
   - Direct employee to medical provider directory if emergency  medical care is not needed
3. Supervisor must complete, with the employee where possible, the DAS WC Claim Packet
4. Supervisor reports claim to TPA injury reporting hotline 1-800-828-2717
5. Supervisor forwards completed claim packet to Agency workers’ compensation office or applicable DAS Pod for CORE-CT processing and review.

RECURRENCE CLAIM REPORTING PROCEDURE

An injured employee must immediately report a recurrence to his/her supervisor and human resources department, providing as much of the following information as possible:

  - Original date of Injury
  - Original Claim Number
  - Details of the recurrence
  - What medical facility he/she is treated at for the recurrence
  - Submit the medical disposition supporting the recurrence

The supervisor or human resources department, depending on the agency reporting structure, will phone the recurrence information to the TPA by dialing 860-256-3400 then press 7, which will take you to the recurrence desk.