When an employee is injured at work, the top portion of the Request for Treatment form should be completed by the supervisor and signed by the injured employee. He/she should then take the form to the first treatment center.
After evaluating the injured worked, the first treatment center will complete the form, providing copies to The Workers' Compensation Trust, the employer and the employee.
A supply of these forms should be maintained at all company sites. If you need additional forms please call (203) 678-0100.
The Connecticut Workers' Compensation Commission requires a filing status and exemption form be completed for all employees injured on or after October 1, 1991. This form, in addition to the wage statement, is necessary to calculate the employee's compensation rate.
The Trust sends the form directly to the claimant once we have received notification of an injury.