Order To Second Injury Fund In Cases Of Concurrent Employment
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Order To Second Injury Fund In Cases Of Concurrent Employment Form. This is a Connecticut form and can be use in Workers Compensation.
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Tags: Order To Second Injury Fund In Cases Of Concurrent Employment, 44, Connecticut Workers Compensation,
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44
Rev. 3-17-2006
State of Connecticut
Workers’ Compensation Commission
WCC File #
Date filed in District
Order to Second Injury Fund
in Cases of Concurrent Employment
The Insurer / Payor shall furnish the Treasurer such documents as is necessary to verify payments for
which it is seeking reimbursement.
(for WCC use only)
ORDER
CLAIMANT
Pursuant to C.G.S. Section 31-310, the Treasurer of the
State of Connecticut is ordered to reimburse the subject
Insurer / Payor for the prorated share it has expended
under Voluntary Agreement approved on
Name
Soc. Sec.# (optional)
D.O.B.
Address
City/Town
(date)
for the captioned injury.
Zip Code
The Insurer / Payor attests that it has paid the complete
adjusted total weekly benefit as agreed to on the subject
Voluntary Agreement and now seeks reimbursement for the
prorated share in the amount of
$
State
Tel.#
INJURY
Date of Injury
EMPLOYER
for the weekly periods enumerated below, check to be
made payable to:
Name
Address
City/Town
Temporary Total Benefits
from
Zip Code
= $
to
State
Tel.#
INSURER / PAYOR
Temporary Partial Benefits = $
Name
from
Address
to
City/Town
State
Permanent Partial Benefits = $
Zip Code
from
............................................................................
to
Tel.#
Contact Person
The Form 44 will NOT be processed without both signatures:
WORKERS’ COMPENSATION COMMISSION APPROVAL
Signature of INSURER / PAYOR Representative
Date (MM/DD/YY)
Date (MM/DD/YY)
Sent to SIF
Signature of SECOND INJURY FUND Representative
Date (MM/DD/YY)
(for WCC use only)
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