Report an Injury

Connecticut Claim Reporting

Employer’s First Report of Injury

Employee, Personal and Wage Information
Accident Information
Employer and Insured Information
Additional Information
Comments
Attachments
Before You Submit

Need Help?

If you’re unsure whether this is the right reporting path, contact A.I.M. Mutual before submitting.

Connecticut Claim Reporting
Employee, Personal and Wage Information
Employee details
Employee’s Name

Employee’s First NameEmployee’s Middle NameEmployee’s Last Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Does the employee have a Social Security Number?
Social Security Number
Example 123-45-6789. Dashes optional.
Date of Hire

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Contact information
Employee's Address

Street Address

Street Address Line 2

CityState

Zip Code
Gender
Marital Status
Primary Language
Job Title
Employee's Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Employee's Email Address
example@example.com
Wage and employment information
Number of Dependents
Average Weekly Wage
Is this wage estimated or actual?
Full Pay for Day of Injury?
Employment Status
NCCI Class Code (if known)
Rate of Pay
Pay Frequency

Accident Information
Injury dates and employer knowledge
Date of Injury

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Injury

Hour Minutes

AM/PM Option
Time Employee Began Work

Hour Minutes

AM/PM Option
Last Day Worked

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer First Knowledge of Injury Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer Knowledge of Disability Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Injury and exposure details
Nature of Injury
All Equipment, Materials and/or Chemicals Employee Was Using When the Accident or Illness Exposure Occurred
Specific Activity and/or Work Process Employee Was Engaged in When the Accident or Illness Exposure Occurred
Briefly Describe How Injury/Exposure Occurred, and Body Part(s) Involved
Example: Worker hit their right knee on the corner of the desk while lifting office equipment.
Work status and wage incapacity
Has Employee Returned to Work?
If yes, please provide the return-to-work date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
First Day of Total or Partial Incapacity to Earn Wages

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Third Day of Total or Partial Incapacity to Earn Wages

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If the Employee Has Died, Date of Death

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Location and witnesses
Was Employee Injured on Employer’s Premises?
Location of Injury if Not on Employer's Premises
If no, provide the location of injury.
Was the Employee Out of Work for Four or More Days?
Witness(es) to Injury. Give full name(s). If none, state as such.
Witness(es) to Injury Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Were Safeguards or Safety Equipment Provided?
If Safeguards or Safety Equipment Were Provided, Were They Used?

Employer and Insured Information
Employer and policy
FEIN
SIC Code
Employer’s Name
Employer's Address

Street Address

Street Address Line 2

CityState

Zip Code
Employer’s Telephone Number
Employer’s Email Address
example@example.com
WP Policy Number, 13 Positions

Additional Information
Treatment information
Has the Employee Received Medical Treatment?
Please Provide the Provider’s Name
Initial Treatment
Report details
Name of Person to Whom Injury Was Reported
Job Title of Person to Whom Injury Was Reported
Date Employee Reported Injury

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name and Title of Person Submitting This Claim
Submitter’s Email Address
example@example.com
Date Submitted

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Comments
Use this space to provide any additional details about the employee or injury that were not captured above.
Comments/Issues/Concerns

Attachments
Please upload any pertinent documentation related to the injury to assist in the claim investigation, such as medical records, work status forms, accident reports, photos, and witness statements.
File Upload

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Before You Submit
After submitting this injury report, you will receive a confirmation email indicating that your report has been successfully received.

If additional information is needed, an A.I.M. Mutual team member may contact you within 48 hours. If you do not receive the confirmation email within a few hours, please reach out to us directly to ensure your injury report was received.
OSHA Reporting
Employers must report serious injuries within 24 hours and fatalities within 8 hours to OSHA.
Call 1.800.321.6742 or report online through OSHA.
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Connecticut Claim Reporting

Need Help?

Connecticut Claim Reporting

Employee, Personal and Wage Information

Employee details

Contact information

Wage and employment information

Accident Information

Injury dates and employer knowledge

Injury and exposure details

Work status and wage incapacity

Location and witnesses

Employer and Insured Information

Employer and policy

Additional Information

Treatment information

Report details

Comments

Attachments

Before You Submit

OSHA Reporting