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THE A <br />• • / • <br />INSTRUCTIONS <br />EMPLOYEE'S CLAIM FOR WORKERS' COMPENSATION BENEFITS <br />As of CAn❑ary 1, 1990, California employers are re❑fired ❑y law to finis❑ a claim form to an in —red worer witJn one <br />wordng day of ❑nowledge of a wor- related inky or illness Cot❑er t❑an First Aid❑ Wile it is mandatory for t❑e employer <br />to finis❑ t❑e claim form to t❑e employee, it is not mandatory for the employee to complete it. <br />T❑e employer s❑bdd complete sections 9-1 ❑, wit❑ t❑e eeeption of section 13 [VvE]c❑ reads, "Date employer <br />recei[od claim form"❑ T❑is is to ❑e completed after t❑e claimant es completed Els or ❑er portion of t❑e claim <br />form and ret-ned it to yoq at wE]c❑time section 13 s❑bdd ❑e immediately filled oEt or date stamped. <br />Penalties can e in❑bed if employers fail to proElde an in❑red employee an EMPLOYEEiS CLAIM FOR <br />COMPE❑SATIO❑ BE❑EFITS form or if employers fail to report t❑e claim to tie worers❑compensation <br />ins-rance carrier. <br />DO NOT DELAY REPORTING A CLAIM TO THE HARTFORD: <br />W❑et❑er or not tie employee completes t❑e EMPLOYEES CLAIM FOR WOR❑ERIS COMPE❑SATIO❑ <br />BE❑EFITS, please contact T❑e ❑artfordig LossConnect (1-800-327-3636) to report eery occ-pational in—ry or <br />illness w❑ic❑resdts in lost time eyond t❑e date of tie incident or re -gyres medical treatment eyond First Aid. <br />Form WC 55 00 11 D Printed in O.S.A. <br />