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Teas Regional Office <br />UIJT!MFUUFS!DPOUBJOT!JNQPSUBOU!JOGPSNBUJPO/ <br />40 Gears Road, Site 00 <br />QMFBTF!SFBE!DBSFGVMMZ!BOE!SFUBJO!UIJT!MFUUFS <br />oston, T 06-48 <br />P.O. Bo 4611 <br />GPS!GVUVSF!VTF/ <br />oston, T 210-4611 <br />Telepone 281 84-9600 <br />TOWORERS COMPESATIO POLICYOLDERS I TEAS <br />TanyoforcoosingTeartfordasyorworerscompensationcarrier.Weastatyotaeamintetofamiliarie <br />yorself wit te forms and reporting reirements for te State of Teas wic we ae inclded in tis pacet. <br />1.Eacemployersoldmaintainarecordofallinriesreportedormadenowntoteemployer.TeTeas <br />Department of Insrance, Diision of Worers Compensation DWC may at times reest tese records for reiew. <br />2.Ifteinrycasesanemployeetoeoffwormoretanoneday PS inoleaclaimforanoccpationaldiseaseyo <br />mst immediately report te loss. <br />3.Please refer to Form WC 66 02 1 for LossConnect loss reporting instrctions. <br />4.LossConnect will file all necessary state reports. <br />.TECLAIMMSTBEREPORTEDOLATERTATEEIGTDAYAFTERTELOSSOFOEDAYOF <br />WORORTEFIRSTOTICEOFAOCCPATIOALDISEASE.FAILRETOCOMPLYMAYRESLTIA <br />ADMIISTRATIE IOLATIO WIC COLD ICLDE P TO A 00.00 FIE. <br />6.TeFROImstefiledeenonadotflordisptedclaim.Yorlacofnowledgeofteclaimdetailssolde <br />reflected on te report. <br />DPNQMFUJPOPGBGSPJJTOPUDPOTJEFSFEBOBENJTTJPOPGPSFWJEFODFPGBDPNQFOTBCMFJOKVSZ <br />JG!UIF!GBDUT!DPOUBJOFE!UIFSFJO!BSF!MBUFS!DPOUSBEJDUFE/ <br />.TeEmployersWageStatementDWC-3soldeproidedtotecarrier,employee,andDWCifyonowor <br />epect 8 days of disaility. <br />8.TeSpplementalReportofInryDWC-6soldefiledwittecarrierweneeryoasteemployerare <br />aware of any cange in wor stats or earnings de to te inry.DO OT SED TO TE DWC. <br />We,astecarrier,cannotacticlyandefficientlyinyorinterestnlessimmediatenoticeofaninryisreceied.Yor <br />cooperation is imperatie and we stand to assist yo in any way we can. <br />Te artford Insrance Grop <br />Gpsn!XD!66!11!33!B Printed in .S.A. <br />artford Fire Insrance Company and its Affiliates <br />artford Plaa, artford, Connectict 0611 <br /> <br />