COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::2002 State of Connecticut Workers' Compensation CommissionIndex No.22-7-Calendar No.Rev.Date filed in Chairman's OfficeJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)FilepursuanttoC.G.S.ยง31-316 forinjuriesthatresultinINCAPACITYFORONEDAYOR MORE. PleaseTYPE or PRINTIN INK.(for WCC use only) FRI Employer's First Report of Occupational Injury or Illness Send this form to: Workers'Compensation Commission, 21 Oak Street, Hartford, CT06106-8011Report Purpose CodeOSHA Log Case # EMPLOYEREmployer (Name, Address & Zip)Phone #Jurisdiction Claim # JurisdictionEmployer's Location Address (if different) Carrier / Administrator Claim #Phone #. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SIC CodeFEINCARRIERCLAIMS ADMINISTRATORTHE PEOPLE OF THE STATE OF NEW YORK TOCarrier (Name, Address & Zip)Claims Administrator (Name, Address & Zip)Phone #Phone #POLICYGREETINGS:Policy / Self-Insured #Policy Period (MM/DD/YY) FROM:TO: Check, if Self-InsuredWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableEMPLOYEEWAGE,First NameMiddle NameState of HireGenderlocated at County ofOccupation / Job Title Date Hired (MM/DD/YY)Address (incl. Zip) Last NamePhone #o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room MaleNCCI Class CodeRate of Pay $ . per FemaleDate of Birth (MM/DD/YY)Social Security # Other Bi-Weekly Week Day HourYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.OCCURRENCEDate of Injury / Illness (MM/DD/YY)Town of Injury / IllnessTREATMENT Physician / Health Care Provider (Name, Address & Zip)Time Employee Began Work a.m. p.m.Did Injury / Illness occur on Employer's Premises? Yes No, one of the Justices of theTime of OccurrenceType of Injury / IllnessCourt in Witness, Honorableday of, 20 County, a.m. p.m. cannot be determinedPart of Body AffectedHospital (Name, Address & Zip)Date Employer Notified (MM/DD/YY)Type of Injury / Illness Code(Attorney must sign above and type name below)Date Disability Began (MM/DD/YY)Part of Body Affected CodeDate Last Worked (MM/DD/YY)Were Safeguards or Safety Equipment provided? If provided, were they used?Initial Treatment Yes No Yes NoAttorney(s) forDate Return(ed) to Work (MM/DD/YY) Emergency Care No Medical TreatmentIf Fatal, Date of Death (MM/DD/YY)How Injury / Illness Occurred Describe the sequence of events, including any objects or substances that directly injured the employee or made the employee ill: Hospitalized More Than 24 Hours Minor by Employer Future Major Medical Lost Time Anticipated Minor by Clinic / HospitalAll equipment, materials, and/or chemicals employee was using when accident or illness exposure occurred:Office and P.O. AddressPREPARERDate Prepared (MM/DD/YY)Date Administrator Notified (MM/DD/YY)Specific activity and/or work process employee was engaged in when accident or illness exposure occurred:Telephone No.: Facsimile No.: E-Mail Address:Preparer's Name & TitlePhone #Contact NameCause of Injury CodePhone #Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com
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