Report an Injury for Connecticut

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*Internet Explorer is not recommended for First Report of Injury submissions*

Fields marked with an asterisk (*) are required—you cannot submit the form unless these fields are completed.

1. Employer's name*

2. Telephone Number*

3. Address (No., Street, City, State & Zip Code)*

4. SIC Code

5. FEIN

6. Carrier / Administrator Claim #

7. OSHA Log Case #

8. Report Purpose Code

9. Jurisdiction

10. Jurisdiction Claim #

11. Employer's Location Address (if different)

12. Telephone Number*

13. Carrier Name*

A.I.M. Mutual Insurance Co. Associated Employers Insurance Company

14. Telephone Number

15. Address (No., Street, City, State & Zip Code)

16. Self-Insured?

Yes No

17. Policy / Self Insured #*

18. Policy Period From (mm/dd/yyyy)

19. Policy Period To (mm/dd/yyyy)

20. Employee's Name*

21. Date of Birth (mm/dd/yyyy)*

22. Employee Telephone Number

22 a. Phone Type

Home Cell Work

22 b. Employee Personal Email Address

23. Gender*

Male Female

24. Address (No., Street, City, State & Zip Code)*

25. Date of Hire (mm/dd/yyyy)*

26. State of Hire*

27. Occupation / Profession*

28. NCCI Class Code*

29. Rate of Pay*

Employee Status*

Full Time Part Time Seasonal

30. Pay Frequency*

Hourly Daily Weekly Bi-Weekly Other

31. Date of Injury / Illness (mm/dd/yyyy)*

32. Town of Injury / Illness

33. Time Employee Began Work*

34. Did Injury / Illness Occur on Employer's Premises?*

Yes No

35. Time of Occurrence*

36. Date Employer Notified (mm/dd/yyyy)*

37. Date Disability Began (mm/dd/yyyy)

38. Date Last Worked (mm/dd/yyyy)*

39. Date Returned to Work (mm/dd/yyyy)

40. If Fatal, Date of Death (mm/dd/yyyy)

41. All equipment, materials and/or chemicals employee was using when accident or illnes exposure occured

42. Specific activity and/or work process employee was engaged in when accident or illnes exposure occured

43. Type of Injury / Illness*

44. Part of Body Affected*

45. Type of Injury / Illness Code

46. Part of Body Affected Code

47. Were Safeguards or Safety Equipment Provided?

48. If provided were they used?

Yes No

49. How Injury / Illness Occurred - Describe the sequence of events, including any objects or substances that directly injured the employee or made the employee ill*

50. Physician / Health Care Provider Name

51. Address (No., Street, City, State & Zip Code)

52. Hospital Name

53. Hospital Address (No., Street, City, State & Zip Code)

54. Initial Treatment

No Medical Treatment Minor - By Employer Minor - By Clinic/Hospital Emergency care Hospitalized more than 24 Hours Future Major Medical - Lost Time Anticipated

55. Date Administrator Notified (mm/dd/yyyy)*

56. Date Prepared (mm/dd/yyyy)*

57. Preparer's Name

58. Preparer's Title*

59. Preparer's Phone #

60. Contact name*

61. Telephone Number*

62. Cause of Injury Code

63. E-mail*

64. Comments

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