CT DAS WC 207 free printable template
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DAS Central Office use only Incident No Reference No First Report of Injury WC 207 Claim No The Supervisor must complete this form with the employee and forwar your Agenc s orkers ency then forward it to your Agency s Workers Compensation specialist within 24 hours after the incident. 1. AgencyLocationCode 2. Division/Region 3. SSN 4. Employee Number 5. Name of Injured Worker First Last MI 6. Home Address City or Town State Zip 7. Home Telephone...
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How to fill out CT DAS WC 207
How to fill out CT DAS WC 207
01
Obtain the CT DAS WC 207 form from the Connecticut Department of Administrative Services website or your employer.
02
Fill in the employee's personal information, including name, address, and social security number at the top of the form.
03
Provide details about the employer, including the business name, address, and their workers' compensation insurance information.
04
Indicate the date of the incident and describe the nature of the workplace injury or illness briefly.
05
Specify the location where the injury occurred, including any relevant details about the job site.
06
Include names and contact information of any witnesses to the incident.
07
Sign and date the form at the bottom to confirm that the information provided is accurate.
08
Submit the completed form to your employer and keep a copy for your records.
Who needs CT DAS WC 207?
01
Employees who have suffered a workplace injury or illness.
02
Employers who are required to document workplace injuries as part of their workers' compensation obligations.
03
Insurance providers who need to assess and process workers' compensation claims.
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What is CT DAS WC 207?
CT DAS WC 207 is a form used for reporting workers' compensation insurance premiums in the state of Connecticut.
Who is required to file CT DAS WC 207?
Employers in Connecticut who have workers' compensation insurance and need to report their payroll and related information are required to file CT DAS WC 207.
How to fill out CT DAS WC 207?
To fill out CT DAS WC 207, employers must provide information regarding their business, payroll, and any other relevant details as specified on the form.
What is the purpose of CT DAS WC 207?
The purpose of CT DAS WC 207 is to ensure accurate reporting of workers' compensation premiums and to verify compliance with state regulations.
What information must be reported on CT DAS WC 207?
CT DAS WC 207 requires reporting of details such as the type of business, total payroll, number of employees, and classification codes for workers.
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