With the DAS HR Worker’s Compensation (DAS HRWC) Centralization effective 8/28/2020, DEEP falls under the General Government Pod. Current contact for DEEP WC Claims is:

• Jolie Hinners jolie.hinners@ct.gov p: (860) 937-6374

All WC injuries must have the following forms completed and sent to us at DAS_RfaxWCGG@ct.gov or by fax at 860-730-8316.
Supervisor: 207 & 207-1
Employee: 1A, 211, 715 and new DAS WC Acknowledgement Form (for use effective 5/12/2022)

Employee must sign the DAS WC Acknowledgement Form and submit it with the other required forms in this process to DAS Worker’s Compensation Pod within 24 hours of the injury.

All initial forms (207, 207-1, 1A, 211, 715 and work status forms) should always be sent as soon as possible after the claim is called into Gallagher Bassett (GBS) by email or fax to DAS HRWC: DAS_RfaxWCGG@ct.gov or 860-730-8316 (fax). Whomever (normally the Supervisor) is sending the forms confirm with them if there are any restrictions or if the employee is currently out of work.

What Stays the Same with the Centralization:

• As in the past, the employee is still responsible to report the work related injury or illness to their Supervisor and assist in the completion of the documents noted in this memo.


• The Supervisor still refers to the Agency claim packet or can find the fillable pdf forms at the DAS WC Forms Website- Workers' Compensation Rights, Responsibilities, and Claims--Documents (ct.gov) for the Workers’ Compensation (WC) forms necessary to report and process a WC claim.


• Injuries are reported to the Supervisor, who fills out the DAS Form 207/First Report of Injury and the DAS Form 207-1/Accident Investigation Forms.


• The Supervisor calls in the claim to the State’s third-party administrator, Gallagher Bassett (GBS) at 1-800-828-2717. This is the same number found at the bottom of the DAS Form 207.


• The Supervisor still coordinates efforts with the injured employee to provide and complete the remaining WC packet forms that are needed for processing including:
• DAS Form 715/Use of Accruals
• WCC Form 1A/ Filing Status
• DAS PER-WC Form 211/ Third-Party and Concurrent Employment
• DAS Form 208/ Physician Form for Medical Visit


• The Supervisor and/or Agency Business Partner/Centralized HR representative(s) will continue to coordinate efforts with the WC contacts to return the injured employee to work.

What Changes in Centralization:

• The Supervisor will notify their Agency-specific HRWC Pod of a new injury via pod-specific fax (“Rightfax”) or Rightfax email.


• The Supervisor will send the completed DAS Form 207 and DAS Form 207-1, and accompanying forms if available to their HRWC Pod. If an employee has a recurrence, they must report it to their Supervisor.


• The Supervisor sends the appropriate forms (DAS Form 715 and DAS PER-WC Form 211), and any associated medical note and work status reports to the General Government (GG) Pod via: Pod RightFax email/Fax: DAS_RfaxWCGG@ct.gov (email) 860-730-8316 (fax) NOTE - Check your agency outgoing call/fax procedure for dial-out prefixes (9, etc).


• The General Government HRWC Pod staff will follow up with the injured worker to obtain any missing forms after initial effort by the Supervisor, in time for processing deadlines. These documents are very important to determine proper wage replacement benefits, if applicable.


• The Supervisor and/or Business Partner will notify their applicable HRWC Pod contact of any changes in work status from a medical provider (“out of work” notice or “return to work” notice) received from the injured employee, and send them to the applicable HRWC Pod via fax or Rightfax email.


• The applicable HRWC Pod staff will process the claim rather than the Agency. This means the Pod staff will:
• Create a WC file
• Provide Agency Time & Labor/Payroll personnel with appropriate coding for Agency completion of timesheets.
• Complete entries in Core-CT for employees going out of work due to a workplace injury or returning to light, recoup post (DOC only), or full duty.
• Work with Gallagher Bassett and the Agency Business Partners and supervisor on return-to-work efforts.
• Work with Agencies to complete reconciliations that are needed for restoration of accruals, if applicable.
• HRWC Pod Managers will assign their staff to process Agency WC claims based on individual Pod needs. The Pod Managers will communicate their staff contact information to their applicable Agencies.

Medical Treatment:
Medical Treatment - Injured employees seeking medical treatment are directed to receive treatment from a provider within the Gallagher Bassett Services, Inc./Prime Health Medical Provider Network directory.

Directories are available through:

• Dialing Prime Health Directly at 1-866-348-3887
• Internet: Visit the DAS Workers’ Compensation web page under Medical Provider and Pharmacy Directory Look-up.

Receiving treatment outside the Gallagher Bassett Services, Inc./Prime Health Medical Provider Network may jeopardize your entitlement to available workers’ compensation benefits, subject to the jurisdiction of the Workers’ Compensation Commission.

To Locate a Doctor, Hospital, or Pharmacy in the Workers' Compensation Network, go to Locate a Doctor, Hospital, or Pharmacy in the Workers' Compensation Network--How To and click on “Find a Network Medical Provider” or “Find a Network Pharmacy.

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Additional Materials and Forms

State of Connecticut Worker’s Compensation Program-Employee Information Brochure

WC Medical Treatment and New Initial Treatment Provider Network Guidelines

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DAS Workers’ Compensation Report Packet

DAS WC Acknowledgement Letter - Signature Required

DAS Form 207 - First Report of Injury

DAS Form 207-1 - Incident Review Report

WCC Form 1A - Filing Status and Exemption

DAS Form PER-WC 211 - Concurrent Employment and Third Party Liability

DAS Form WC-715 - Request for Use of Accrued Leave With Workers' Compensation

DAS Form 208 – Worker Status Report