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