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THIS LETTER CONTAINS IMPORTANT INFORMATION. <br />PLEASE READ CAREFULLY AND RETAIN THIS LETTER <br />FOR FUTURE USE. <br />TO-- WOR❑ERS-COMPE❑SATIO❑ POLICY❑OLDERS 1❑ TE❑AS <br />THE A <br />• • / • <br />TeCas Regional Office <br />4C0 Gears Road, SEJte 000 <br />❑oi-ston, Tu uLI6a4C8❑ <br />P.O. BoL14611 <br />❑oCston, To 0E210-4611 <br />TelepEjone [2810804-9600 <br />T❑an❑yo❑for c oosing T❑e ❑artford as yob wor ers compensation carrier. We as❑t❑at yo❑tae a min to to familiarie <br />yoEirselfwit❑t❑e forms and reporting re❑Eirements for t❑e State of TeE:is wElc❑we ❑ae incl❑ded in t'js pac et. <br />1. Eac❑ employer s❑bdd maintain a record of all in -Ties reported or made ❑sown tote employer. T❑e Tees <br />Department of Instance, Di:jsion of Worers❑Compensation :DWC-may at times re❑❑est tese records for resew. <br />2. Ift❑e inky cases an employee to ❑e off wor❑more t❑an one day OR in❑bl❑e a claim for an occ-pational disease yo❑ <br />mC:8t immediately report t❑e loss. <br />3. Please refer to Form WC 66 02 ❑1 for LossConnect loss reporting instr❑ctions. <br />4. LossConnect will file all necessary state reports. <br />❑ T❑E CLAIM MOST BE REPORTED ❑O LATER TOAD TOE EIG❑T❑ DAY AFTER T❑E LOSS OF O❑E DAY OF <br />WORD OR T❑E FIRST ❑OTICE OF All OCC❑PATIO❑AL DISEASE. FAIL❑RE TO COMPLY MAY RES❑LT 1❑ All <br />ADMI❑ISTRATI❑E ❑IOLATIO❑ W❑IC❑ CO❑LD I❑CL❑DE ❑P TO A 11E00.00 FI-E. <br />6. T❑e FROI mC:8t ❑e filed een on a do❑❑tff:l or disp❑ted claim. Yoh lac❑of Enowledge of tie claim details siedd ❑e <br />reflected on t❑e report. <br />COMPLETION OF A FROI IS NOT CONSIDERED AN ADMISSION OF OR EVIDENCE OF A COMPENSABLE INJURY <br />IF THE FACTS CONTAINED THEREIN ARE LATER CONTRADICTED. <br />Fi Te Employers Wage Statement DWC-3❑s❑bdd ❑e pro:jded to tie carrier, employee, and DWC if yo❑ E1ow or <br />e-pect 8 days of disa::jlity. <br />8. T❑e S-pplemental Report of In❑ry EDWC-6❑s❑bdd ❑e filed wit❑ t❑e carrier weneer yo❑ [as to employer -are <br />aware of any cenge in wor❑statC:8 or earnings de to t❑e in—ry. DO ❑OT SE❑D TO T❑E DWC. <br />We, as tie carrier, cannot act 11EJc1y and efficiently in yo-r interest _nless immediate notice of an inky is receied. Yoh <br />cooperation is imperati e and we stand to assist yo❑ in any way we can. <br />Form WC 55 00 22 A Printed in O.S.A. T-e-artford Ins-rance Gro—p <br />-artford Fire Ins—rance Company and its Affiliates <br />-artford PlaE8, Cartford, Connectic-t 0611- <br />