The following steps should be taken when a work related injury or incident occurs.

Complete the Employee Incident Report

Please note: In the event of a catastrophic claim, contact Atlantic Charter Insurance Company immediately at 617.488.6500. This report should be completed jointly by the employee’s supervisor and the injured employee.

  • Section 1
    General Information

    Section 1 documents general information about the employee, when and where the incident occurred, who was involved, what treatment has occurred, and the employee’s current work status.

  • Section 2
    Employee’s Statement

    Section 2 should be completed by the injured employee. Only the employee should write a detailed statement explaining what occurred and what injury resulted. The employee should then sign the statement where it is indicated.

  • Section 3
    Employee’s Medical Authorization

    Section 3 is a medical release which the employee should be asked to sign. This release allows Atlantic Charter Insurance Company to access medical information pertaining to the injury which the employee is alleging.

Determine if the incident will result in four or more calendar days of incapacity

Incidents that require medical treatment, but result in less than four calendar days of incapacity are considered “Medical Only” claims. They should be reported to Atlantic Charter Insurance Company via the Employee Incident Report. Please include any other supporting documentation. Notice to the state/Department of Industrial Accidents is not required.

An Employer’s First Report of Occupational Injury or Illness must be filled out for any injured employee who is incapacitated and unable to earn full or partial wages for four or more calendar days. The days do not need to be consecutive. The form must be filed with the Workers’ Compensation Commission within seven days of notification of the injury.

Please be advised that Atlantic Charter Insurance Company and its affiliates will file First Reports with the Workers’ Compensation Commission on your behalf.

For your convenience, you can access an electronic copy of the First Report of Occupational Injury or Illness. A printed, completed copy of the First Report must be sent to Atlantic Charter Insurance Company (using the methods described in the adjacent box), given to the injured worker, and kept with your file.

Please note that late reporting by the employer may result in a fine being levied by the Workers’ Compensation Commission.

The Employee Incident Report and Supervisor Investigative Report must also be submitted to Atlantic Charter Insurance Company.

The employee should receive a Form 1A and CT Medical Authorization to complete and submit to Atlantic Charter Insurance Company.