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�.g <br />A <br />THE <br />• , • 1 <br />INSTRUCTIONS <br />EMPLOYEE'S CLAIM FOR WORKERS' COMPENSATION BENEFITS <br />As of January 1, 1990, California employers are required by law to furnish a claim form to an injured worker within one <br />working day of knowledge of a work -related injury or illness (other than First Aid). While it is mandatory for the employer <br />to furnish the claim form to the employee, it is not mandatory for the employee to complete it. <br />The employer should complete sections 9-17, with the exception of section 13 (which reads, "Date employer <br />received claim form"). This is to be completed after the claimant has completed his or her portion of the claim <br />form and returned it to you, at which time section 13 should be immediately filled out or date stamped. <br />Penalties can be invoked if employers fail to provide an injured employee an EMPLOYEE'S CLAIM FOR <br />COMPENSATION BENEFITS form or if employers fail to report the claim to the workers' compensation <br />insurance carrier. <br />DO NOT DELAY REPORTING A CLAIM TO THE HARTFORD: <br />Whether or not the employee completes the EMPLOYEE'S CLAIM FOR WORKER'S COMPENSATION <br />BENEFITS, please contact The Hartford's LossConnect (1-800-327-3636) to report every occupational injury or <br />illness which results in lost time beyond the date of the incident or requires medical treatment beyond First Aid. <br />Form WC 55 00 11 D Printed in U.S.A. <br />Rime Mattagmient DMsion <br />REVIEWED&APPROVED BY: <br />f aaa.o:.a.e Z V: @Q44z <br />'� Risk Management Analyst <br />