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Hartford Workers' Compensation Claim Form

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APPLICATION FOR LONG TERM DISABILITY INCOME BENEFITS

HARTFORD LIFE INSURANCE COMPANY
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY

Please complete all sections fully. Forward the completed application to your Hartford Benefit Management Service Center.

Section I - Employer's Statement - to be completed by the employer's authorized representative.

A. Information About the Employer

B. Information About the Employee

Was the employee's LTD insurance issued on the basis of a Personal Health Statement? Yes No

Was the employee insured under your prior LTD policy? Yes No

Has the employee been terminated? Yes No

Was the employee on Qualified Family Leave when disability began? Yes No

Did LTD insurance continue while on Family Leave? Yes No

C. Information for Group Life Premium Waiver Benefits

Does the employee also have Group Life Insurance coverage with The Hartford? Yes No

D. Information Needed for Withholding and Reporting Taxes

Does the employee contribute towards the cost of the LTD premium? Yes No

If yes, is it on a Pre Tax Post Tax basis?

Is the condition work related? Yes No

Has a claim been filed with Workers' Compensation? Yes No

E. Information About the Claim

F. Information About Your Pension Plan

Do you have a pension plan? Yes No

Type: Defined contribution Profit Sharing Defined benefit 401 K Other

Is the employee eligible? Yes No

Does the employee participate? Yes No

Disability Retirement Option available? Yes No

G. Rehire or Return-to-Work Policies

Rehire or return-to-work policy? Yes No

H. Information About the Employee's Salary

Salary continuation or Sick Pay? Yes No

Short Term or State Disability benefits? Yes No

I. Information About the Physical Aspects of the Employee's Job

Activity frequency table and job tasks as listed in the PDF should be completed below.

Balancing Sitting Walking Stooping Kneeling Crouching Crawling Reaching/working overhead Keyboard Use/Repetitive Hand Motion Climbing

Can the job be performed by alternating sitting and standing? Yes No

J. Information About the Job as it Relates to the Disability

K. Required Attachments and Signature

Please attach a copy of the employee's job description and other requested supporting documents listed in the PDF.

Section II - Employee's Statement

To be completed by the employee. Be sure to answer all questions.

A. Information About You

Gender: Male Female

May we leave confidential medical and benefit information on your personal cell phone? Yes No

Marital Status: Single Married Divorced Widowed

Did you have more than one employer when disability began? Yes No

Have you ever served in the military? Yes No

Interested in rehabilitation to other work? Yes No

Contacted State Department of Vocational Rehabilitation? Yes No

B. Information About Your Family

Is your spouse employed? Yes No Retired Yes No

Children under 19? Yes No

Children with disabilities? Yes No

C. Information About the Condition Causing Your Disability

Have you had this illness before? Yes No

Severe cognitive impairment? Yes No

Changed job or work method before stopping? Yes No

Condition related to occupation? Yes No

Workers' Compensation claim filed/intended? Yes No

D. Information About the Disability

Since that date, have you done any work? Yes No

E. Information About Physicians and Hospitals

F. Other Income

G. Information About Tax Withholding

Section III - Authorization to Obtain and Disclose Information

Signature - Please read the statement that applies to your state of residence and sign the bottom of the page.

Section IV - Attending Physician's Statement of Disability

Patient's condition is the result of: Illness Injury Pregnancy

Condition work related? Yes No

Referred to another physician? Yes No

Has surgery been performed? Yes No

Was patient hospitalized? Yes No

Progress: Recovered Improved Unchanged Retrogressed

Functional Capabilities

Hand dominance: R L

Vision impaired? Yes No

Psychiatric / cognitive impairment? Yes No

Progress: Recovered Improved Unchanged Retrogressed

Competent to endorse checks and direct proceeds? Yes No

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What the Hartford Workers' Compensation Claim Form Is and when it applies

The Hartford Workers' Compensation Claim Form documents an employee's work-related injury or illness to begin a claim with Hartford's insurance services. It records incident details, employer and employee information, medical treatment received, and wage data needed to determine benefits. Employers, injured workers, and medical providers typically complete portions of the form; accurate entries speed adjudication and reduce the chance of follow-up requests. This form is used alongside employer reports, medical records, and state workers' compensation filings to establish coverage, temporary disability payments, or medical expense reimbursement.

Why a complete Hartford Workers' Compensation Claim Form matters

A fully completed Hartford Workers' Compensation Claim Form ensures accurate benefits calculation, faster case handling, and a clearer record for disputes. Clear, consistent answers reduce delays from supplemental information requests and support compliance with state reporting requirements.

Why a complete Hartford Workers' Compensation Claim Form matters

Who typically completes and relies on this form

Each party must enter accurate, legible information; mismatches between employer, employee, and medical sections commonly slow processing.

  • Employers and HR teams who record incident details, payroll data, and initial employer statements about work duties and exposure
  • Injured employees or their representatives who describe the injury, identify treating providers, and report lost time or limitations
  • Medical providers completing treatment sections and providing diagnoses, dates of service, and return-to-work notes

Core sections to expect on the Hartford Workers' Compensation Claim Form

The form is structured to capture event facts, parties, medical treatment, work status, payroll facts, and signatures. Each section supports claim intake, medical authorization, and benefit calculations; consistency across sections reduces the need for follow-up.

Incident Details

Date, time, location, and narrative of how the injury or exposure occurred; critical for compensability.

Employee Information

Full legal name, date of birth, contact, job title, and hire date used for identity and benefit basis.

Employer Data

Company name, address, policy number, supervisor contact, and payroll info needed to calculate wages.

Medical Treatment

Treating provider names, dates of service, diagnoses, and whether care was emergency or scheduled.

Work Status

Return-to-work date, light-duty availability, restrictions, or total temporary disability notation.

Signatures

Employee and employer signature blocks with dates; electronic or handwritten signatures must show intent and attribution.

Step-by-step: Filing a Hartford Workers' Compensation Claim Form

Follow these steps to assemble and submit a complete claim package to Hartford and relevant state agencies.

  • 01
    Collect Incident Facts: Gather date, time, location, witnesses, and immediate treatment details.
  • 02
    Complete Employee Sections: Enter personal data, injury description, and lost-time details.
  • 03
    Employer Review: Employer completes payroll and supervision sections and confirms policy details.
  • 04
    Submit to Hartford: Send the form, medical records, and any employer reports to Hartford and file state-required notices.

Customizing and submitting the form online

Configure your digital workflow so fields, routing, and authentication match corporate and state requirements before sending.

Field Configuration
Required Fields Mark employee name, date of injury, and signature as required
Routing Order Set employer review before insurer submission
Signer Authentication Enable email + SMS or ID verification for sensitive claims
Record Retention Auto-save signed PDF and audit trail to secure storage

Where to file and who receives each copy

A typical submission flow routes the form from employee to employer to insurer, with copies retained for compliance and medical follow-up.

  • Employee to Employer: Employee gives form to HR or supervisor for verification and payroll data
  • Employer to Hartford: Employer sends completed form and employer statement to Hartford claim intake
  • Medical Records: Attach or authorize release of treating provider records to insurer
  • State Agencies: File any state-required employer injury reports per local rules

Distribution and eSubmission channels

Maintain an audit trail and encrypted storage for all signed forms and attachments to meet regulatory obligations.

  • Email Delivery: Send as secure PDF; avoid sending PHI in unencrypted email
  • eSignature Platforms: Use a compliant e-sign provider with audit trail and BAA support for HIPAA data
  • Integration Options: Connect with HRIS, claims management, or cloud storage for automated routing

Key timelines and deadlines to track

Timely filing and prompt medical documentation are essential; deadlines include state notice rules and payroll-based calculations for benefits.

Immediate Reporting:

Report to employer as soon as practicable after injury

Employer State Filing:

Some states require employer report within 7–30 days

Medical Records:

Submit initial treatment notes with claim to avoid delays

Wage Verification:

Provide payroll records promptly when requested

Appeals Deadlines:

Observe state-specific timeframes for challenging denials

Key claim milestones from injury to resolution

A typical claim progresses through defined stages; monitoring each milestone helps anticipate next steps.

01

Injury Report Filed

Initial employee notice and employer record entry submitted

02

Claim Intake

Insurer opens claim file and assigns claim number

03

Medical Evaluation

Treating provider documents diagnosis and work status

04

Benefit Determination

Insurer evaluates compensability and issues payment decisions

Common mistakes that slow Hartford claim processing

  • Incomplete incident descriptions lacking key facts and times
  • Mismatched names or dates between employer payroll and employee entries
  • Missing treating provider contact or medical records delaying authorization
  • Using informal language or abbreviations that obscure the injury narrative

Risks and legal consequences of incorrect or late filings

Late Employer Filing: May trigger state penalties or fines for noncompliance
Incorrect Wage Data: Can lead to overpayment recovery or benefit under-calculation
Missing Medical Proof: Claim denial or delay until documentation is provided
Unauthorized PHI Disclosure: Potential HIPAA violations and required breach notifications
Failure to Report: State-specific sanctions and potential civil exposure
Appeal Timebars: Missing appeal windows forfeits review rights

Security and compliance controls relevant to workers' compensation forms

Encryption: AES-256 at rest, TLS 1.2/1.3 in transit
Audit Trail: Timestamps, IP, and action logs retained
HIPAA: BAA available for PHI handling
ESIGN / UETA: Compliant for electronic signature legal validity
SOC 2: SOC 2 Type II certification available
Two-Factor: Optional 2FA for signer authentication

Real-world examples of completing and routing the form

These case sketches show common workflows and outcomes when the form is completed correctly.

Manufacturing Claim

An employee reported a hand injury after machine contact on the same day

  • Employer attached shift log and first-aid notes
  • With complete records the insurer approved medical payments and returned the worker to light duty within two weeks, avoiding prolonged disability payments.

Retail Slip-and-Fall

A customer slip led to employee-assisted cleanup and a sprained ankle claim

  • Surveillance timestamp and supervisor statement were uploaded
  • The documentation established compensable injury and streamlined wage-loss determinations with minimal follow-up.

eSignature vendor pricing and feature snapshot for workers' compensation forms

Compare baseline pricing and commonly used features for eSignature vendors when handling workers' compensation documents; signNow appears first per vendor ordering rules.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No cap 100 envelopes/user/year Varies Varies Varies

Frequently asked questions about the Hartford Workers' Compensation Claim Form

Answers to common issues encountered when completing or submitting the form, including electronic signature and documentation questions.


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