The workers’ compensation packet includes all the required forms that must be completed by both the supervisor and employee. The completed packet can be faxed to Human Resources at 860-486-0406 or securely uploaded by clicking on the following link: WC Related Documents

View and download Workers' Compensation Packet

All State employees are eligible for benefits provided under the State’s workers’ compensation insurance. This includes faculty, staff, student labor, work study, special payroll, and graduate assistants provided that the injury occurred while performing a function related to their employment with the University. The decision to accept or deny a claim is made solely by the Third Party Administrator (TPA).

Types of Workers' Compensation Claims

All reported claims fall into one of three categories:

Report Only:
An incident that is reported by an employee to the supervisor, but no medical attention is being sought.

Medical Only:
An incident that is reported by an employee to the supervisor with corresponding medical treatment, but the injured employee loses no time from work.

Lost Time:
An incident that is reported by an employee to the supervisor with corresponding medical treatment, and the injured worker loses time from work.

It is important to note that all three categories of reported claims require the Form WC207 First Report of Injury, is reported to the TPA injury reporting hotline 1-800-828-2717, and is faxed to Human Resources’ secure fax line: 860-486-0406.

In the case of an emergency, the injured employee should seek treatment at the closest emergency facility. In the case of a non-emergency injury, the injured employee is required to attend the initial visit with one of the designated initial treatment providers. If the injured employee chooses not to visit the designated initial treatment provider or treats outside the workers’ compensation provider network, they may risk suspension of their benefits per order of the Workers’ Compensation Commission.

After the initial visit, the injured employee may choose an attending physician from the State of CT Workers Compensation provider network.

View a complete list of in network providers.

1. Employee immediately reports injury/illness to supervisor.
2. Supervisor must see that the employee receives necessary medical attention: Emergency medical care if necessary.
3. Direct employee to medical provider directory if emergency medical care is not needed.
4. Supervisor must complete the WC207 First Report of Injury.
5. Supervisor reports claim to TPA injury reporting hotline 1-800-828-2717.
6. Within 24 hours, the supervisor faxes the completed WC207 to Human Resources’ secure fax line: 860-486-0406.
7. The employee needs to forward all medical documents relating to the injury. This includes work status reports and appointment sheets for past or future medical treatments.

Please notify Human Resources right away if you are missing work due to the incident or medical treatments.

Form 1A is used to record your federal income tax filing status and number of exemptions for use in establishing your workers’ compensation rate of pay. Please make sure that the number of exemptions you indicate on line 2 matches the number of exemptions you indicate on line 5.

Form WC-715 – Request for use of Accrued Leave with Workers’ Compensation, is used to determine whether or not you wish to use your accrued time while you are out on workers’ compensation leave. Please be aware that workers’ compensation will pay seventy-five percent (75%) of your average weekly wage after taxes, and you can use your accrued time to supplement this payment and receive your normal biweekly payment. Please note that your election on this form cannot be rescinded once it is received.

If you have any questions with regard to the Form 1A or Form WC-715, please contact Tiffanie Roback at 860-486-2598. The address to return the completed form is: University of Connecticut, Department of Human Resources, Attn: Tiffanie Roback, 9 Walters Avenue, Unit 5075, Storrs, CT 06269, or it can be emailed or faxed to (860) 486-0406.

If the injury will result in an absence from work for a period of more than five consecutive workdays, this may qualify the workers’ compensation leave as a “serious health condition” under State and Federal Family Medical Leave Act (FMLA). If the injury will result in an absence from work for a period of more than five consecutive workdays, this may qualify the workers’ compensation leave as a “serious health condition” under State and Federal Family Medical Leave Act (FMLA). Provided the employee is eligible, the workers’ compensation leave will run concurrently with the 12-week State and Federal FMLA leave entitlement.

Full Duty
If the medical documentation indicates a full duty release, the employee must return to their regular position for the next scheduled shift. The employee must provide the medical documentation to Human Resources as soon as possible, during regular business hours, and before their next scheduled shift.Light Duty
If the medical documentation indicates light duty restrictions, the employee must provide the medical documentation to Human Resources as soon as possible. The Workers’ Compensation Administrator will work with the employee’s department to determine if the employee may return to work. The employee should not return to work unless they are contacted by the Workers’ Compensation Administrator and instructed to do so. If it is determined that the employee is able to return to work, they are expected to return for their next scheduled shift.

Please note that certain medical conditions may qualify for accommodation under the Americans with Disabilities Act (ADA). You can get additional information regarding the ADA and your right to an assessment by contacting Ryan Bangham, ADA Accommodations Case Manager at (860) 486-2036 or ryan.bangham@uconn.edu.