Workers Compensation Claim Kit
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1 Workers Compensation Claim Kit
2 Contents Section Welcome I. State of Connecticut Injury Reporting Form II. Wage Statement Form III. State of Connecticut Filing Status and Exemption Form IV. FutureComp Dedicated Claims Unit V. Frequently Asked Questions VI.
3 SECTION I Welcome
4 I am pleased to provide you the FutureComp Workers Compensation Claim Kit. This kit contains all forms, instructions and contacts needed for the recovery of an employees injury and/or illness including: State of Connecticut Injury Reporting Form Used for reporting all accidents Wage Statement Form Used for lost time accidents to calculate the average weekly wage for payment of benefits to an employee State of Connecticut Filing Status and Exemption Form Used with the Wage Statement Form to calculate an employee s workers compensation rate of pay FutureComp Dedicated Claim Unit Your FutureComp contacts, their functions and telephone numbers. Frequently Asked Questions s We look forward to providing you the highest level of service for all your Workers Compensation needs. Please call me if you have any questions. Sincerely, Anthony E. Szwez Senior Vice President, FutureComp (855) Ext
5 Section II State of Connecticut Injury Reporting Form
6 State of Connecticut Injury Reporting Form When to File File this form within seven calendar days (excluding Sundays and legal holidays) of receiving notice of any injury alleged to have occurred in the course of employment. This form is not an admission of liability. It must be filed even if you believe the employee is not injured or that the employee is not entitled to benefits. Where to File or fax to: FutureComp fax: (855)
7
8 Section III Wage Statement Form
9 Wage Statement Form When to File File this form as soon as you know that the injured employee will be absent one or more days from work. This form is used to calculate the injured employee s average weekly compensation. Where to File or fax to: FutureComp fonda.carmody@usi.biz fax: (855)
10
11 Section IV State of Connecticut Filing Status and Exemption Form
12 State of Connecticut Filing Status and Exemption Form When to File File this form as soon as you know that the injured employee will be absent one or more days from work. This form is used with the Wage Statement e t Form to calculate cu ate the injured employee s compensation. Where to File or fax to: FutureComp fonda.carmody@usi.biz fax: (855)
13
14 Section V FutureComp Dedicated Claims Unit
15 Dedicated Claims Unit Tony Szwez Senior Vice President, FutureComp (855) Ext Steve Grahn Claims Manager (855) Ext Judy Burke R.N. Medical Case Management Supervisor (855) Ext Fonda Carmody Senior Claims Adjuster (855) Ext (860) Direct Joanne Glenn Claims Adjuster (855) Ext (860) Direct Melissa Bell, R.N., BSN, CCM Medical Case Manager (855) Ext Sarah Depergola MIS Manager (855) Ext Glastonbury Boulevard, Suite 102 Glastonbury, CT fax: (855)
16 Section VI Frequently Asked Questions
17 Frequently Asked Questions Q. Do the first reports of injury need to be completed in their entirety? A. Yes, all the information is needed to input the claim accurately and monitor the information for loss runs. Q. If an injured employee s medical appointment falls during regular work hours, what do we need to do? A. You are obligated to allow an employee to use paid time off during the workday to attend medical appointments. Q. I am the Workers Compensation Coordinator, who do I call for claim reports? A. Call Sarah Depergola, Data Coordinator, at (855) Ext for loss run information or any customized report requests. Q. May I fax or first reports of injury rather than mail them? A. Yes. Faxing and are preferred delivery methods for first reports of injury. Q. What information is needed to pay a medical bill? A. An itemized bill and a medical report. If the bill is a balance forward or there is no medical report attached, the bill will be sent back to the provider requesting proper information. Q. When mailing claims information or medical bills should we send them to FutureComp or our broker? A. All information regarding workers compensation claims should be sent to FutureComp. Q. When are indemnity/medical/expense reimbursements mailed? A. Reimbursement checks are mailed every Thursday. If Thursday falls on a holiday, checks will be mailed on Wednesday. Q. Do injured employees get reimbursed for mileage, tolls and parking when they have medical visits? A. Yes. The injured employee is paid $.55 per mile. Tolls and parking are paid at face value. Q. How quickly does a new injury need to be reported? A. All injuries should be reported immediately. The sooner FutureComp receives the claim information, the sooner we can help you. The more time that elapses in claim reporting the less information can be gathered. There is also a State-mandate t t that t requires a claim to be reported within seven calendar days. Q. Are employees entitled to any financial remuneration for permanent disability due to work related injuries? A. Yes. The amount of remuneration depends on type and extent of loss. These payments can be made even though the employee may already be back to work.
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