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DocuSign Envelope ID:91 F43AFA-8CB4-4861-887A-F304C7A6614B <br /> Reporting a Work-Related Injury is Time Sensitive! <br /> Call The Hartford's LossConnect immediately to report a claim. <br /> 1-800-327-3636 <br /> Available 24 hours a day, 365 days a year. <br /> The Benefits of Timely Loss Reporting: <br /> Research has shown that faster loss reporting significantly affects loss costs.The sooner we are notified,the <br /> sooner we can investigate the accident and coordinate with you,the injured employee,and the medical team to <br /> ensure the fastest possible return to health and work. <br /> The Effect of Timely Reporting on Controlling the Cost of Your Loss: <br /> Average Loss for Closed Claims <br /> (Accident Years 2002-2005) <br /> Report Lag in Days Percent Change in Loss Costs <br /> Compared to First Week Report <br /> Incident Day -6% <br /> Week 1 0% <br /> Week 2 13% <br /> Week 3 or 4 16% <br /> 1 Month or Later 24% <br /> Statutory requirements also necessitate the prompt initial reporting of the accident <br /> causing injury or death. Failure to comply may result in a fineable offense by the State. <br /> Information You'll Need <br /> Company Information Incident Information <br /> o Account Number o Type of injury(burn,cut, etc.)? <br /> o Location Code(if applicable) o Exact body part injured? <br /> o Parent Company(or program name) o What caused the accident? <br /> o Policy Number o Any reason to question the injury? <br /> o Any witnesses? <br /> Worker Information o Address where injury occurred? <br /> o Name, DOB,Address, Phone o Where was the injured employee treated? <br /> o Social Security Number (Provide name,address, phone of medical <br /> o Age, Gender provider.) <br /> o Marital Status, Number of Dependants o When was the accident reported to you and <br /> o Hire Date,Years in Current Position by whom(date,time)? <br /> o Wage Information <br /> Network Providers <br /> A listing of more than 400,000 network providers qualified to treat work-related injuries is available online at <br /> www.talispoint.com/hartext or by calling our Network Referral Unit at 1-800-327-3636(select 4 at the prompt). <br /> Since network referrals are often impacted by state specific rules, please call to learn how to maximize our <br /> network capabilities on behalf of your employees. <br /> Form WC 66 03 84 Printed in U.S.A. <br />