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INSTRUCTIONS <br />EMPLOYEE’S CLAIM FOR WORKERS’ COMPENSATION BENEFITS <br />AsofJanuary1,1990,Californiaemployersarerequiredbylawtofurnishaclaimformtoaninjuredworkerwithinone <br />workingdayofknowledgeofawork-relatedinjuryorillness(otherthanFirstAid).Whileitismandatoryfortheemployer <br />to furnish the claim form to the employee,it is not mandatory for the employee to complete it. <br />Theemployershouldcompletesections9-17,withtheexceptionofsection13(whichreads,"Dateemployer <br />receivedclaimform").Thisistobecompletedaftertheclaimanthascompletedhisorherportionoftheclaim <br />form and returned it to you, at which time section 13 should beimmediatelyfilled out or date stamped. <br />PenaltiescanbeinvokedifemployersfailtoprovideaninjuredemployeeanEMPLOYEE’SCLAIMFOR <br />COMPENSATIONBENEFITSformorifemployersfailtoreporttheclaimtotheworkers’compensation <br />insurance carrier. <br />DO NOT DELAY REPORTING A CLAIM TO THE HARTFORD: <br />WhetherornottheemployeecompletestheEMPLOYEE’SCLAIMFORWORKER’SCOMPENSATION <br />BENEFITS,pleasecontactTheHartford’sLossConnect(1-800-327-3636)toreporteveryoccupationalinjuryor <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 /> <br />