Fillable NOTICE TO EMPLOYEES State of Connecticut Workers Compensation (American Lumper Services)

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NOTICE TO EMPLOYEES State of Connecticut Workers Compensation (American Lumper Services)

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NOTICE
State of Connecticut Workers’ Compensation Commission
The Workers’ Compensation Act (Connecticut General Statutes Chapter 568) requires your employer,
to provide benets to you in case of injury or occupational disease in the course of employment.
Section 31-294b of the Workers’ Compensation Act states “Any employee who has sustained an injury
in the course of his employment shall immediately report the injury to his employer, or some person
representing his employer. If the employee fails to report the injury immediately, the commissioner
may reduce the award of compensation proportionately to any prejudice that he nds the employer
has sustained by reason of the failure, provided the burden of proof with respect to such prejudice
shall rest upon the employer.”
An injury report by the employee is NOT an ofcial written notice of claim for workers’ compensation
benets; the Workers’ Compensation Commission’s Form 30C is necessary to satisfy this requirement.
NOTE: YoumustcomplywithP.A.17-141(seenextbox,below)whenlingacompensationclaim.
The INSURANCE COMPANY or SELF-INSURANCE ADMINISTRATOR is:
Name
Address Telephone
City/Town State Zip Code
Approved Medical Care Plan Yes No
The State of Connecticut Workers’ Compensation Commission ofce for this workplace is located at:
Address Telephone
City/Town State Zip Code
Public Act 17-141 allows an employer the option to designate and post – “in the workplace location
where other labor law posters required by the Labor Department are prominently displayed” and on
the Workers’ Compensation Commission’s website [wcc.state.ct.us] – a location where employees
must le claims for compensation.
If your employer has listed a location below, you MUST le your compensation claim there.
When ling your claim, you are also required – by law – to send it by certied mail.
If blank below, ask your employer where to le your claim.
Employer Name
Address Telephone
City/Town State Zip Code
TO EMPLOYEES
THIS NOTICE MUST BE IN TYPE OF NOT LESS THAN TEN
POINT BOLD-FACE AND POSTED IN A CONSPICUOUS
PLACE IN EACH PLACE OF EMPLOYMENT. FAILURE
TO POST THIS NOTICE WILL SUBJECT THE EMLOYER
TO STATUTORY PENALTY (Section 31-279 C.G.S.).
Date Posted:
Any questions as to your rights under the
law or the obligations of the employer or
insurance company should be addressed
to the employer, the insurance company, or
the Workers’ Compensation Commission
(1-800-223-9675).
Revised 10-01-2017
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NOTICE TO EMPLOYEES State of Connecticut Workers Compensation (American Lumper Services)

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Completed 29 July 2021

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