Form Notice To Compensation Commissioner And Employee Of Intention To Discontinue Or Reduce Payment
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Form Notice To Compensation Commissioner And Employee Of Intention To Discontinue Or Reduce Payment Form. This is a Connecticut form and can be use in Workers Compensation.
Loading PDF...
Tags: Form Notice To Compensation Commissioner And Employee Of Intention To Discontinue Or Reduce Payment, 36, Connecticut Workers Compensation,
36
Rev. 10-1-2007
IMPORTANT
WCC File #
State of Connecticut Workers’ Compensation Commission
Notice of Intention to Reduce
or Discontinue Payments
Date filed in District
Please TYPE or PRINT IN INK
You are hereby notified that the employer/insurer intends to
REDUCE OR DISCONTINUE your compensation payments on
for the following reason(s):
(for WCC use only)
(date)
(Employer/insurer to explain and attach supporting medical documentation.)
IF YOU OBJECT to the reduction or discontinuation of benefits as stated, YOU MUST REQUEST A HEARING
WITHIN 15 DAYS after your receipt of this notice, OR THIS NOTICE WILL AUTOMATICALLY BE APPROVED.
TO REQUEST AN INFORMAL HEARING, call the Workers’ Compensation District Office in which your case is pending:
(Employer/insurer to check appropriate box.)
1 — Hartford
999 Asylum Avenue
(860) 566-4154
5 — Waterbury
55 West Main Street
(203) 596-4207
2 — Norwich
55 Main Street
(860) 823-3900
6 — New Britain
233 Main Street
(860) 827-7180
3 — New Haven
700 State Street
(203) 789-7512
7 — Stamford
111 High Ridge Road
(203) 325-3881
4 — Bridgeport
350 Fairfield Avenue
(203) 382-5600
8 — Middletown
90 Court Street
(860) 344-7453
Be prepared to provide medical and other documentation to support your objection. For your protection, note the date when you received this notice.
EMPLOYEE
INJURY
Name
Date of Injury
Soc. Sec.# (optional)
City/Town of Injury
D.O.B.
State
Address
Body Part
City/Town
Zip Code
State
Tel.#
Zip Code
Nature of Injury
Cause of Injury
ATTORNEY OR REPRESENTATIVE OF EMPLOYEE
INSURER
Name
Claim Number
Name of Firm
Voluntary Agreement Issued?
Address
City/Town
Zip Code
YES
NO
............................................................................
State
Tel.#
Name
Address
City/Town
EMPLOYER
State
Zip Code
Name
............................................................................
Address
Contact Person
City/Town
Zip Code
State
Tel.#
Tel.#
Date Mailed
THIS NOTICE MUST BE SERVED UPON THE COMMISSIONER AND EMPLOYEE BY PERSONAL PRESENTATION OR BY REGISTERED OR CERTIFIED MAIL.
IF THE CLAIMANT IS REPRESENTED BY AN ATTORNEY, A COPY SHOULD ALSO BE SENT TO THE CLAIMANT’S ATTORNEY.
American LegalNet, Inc.
www.FormsWorkflow.com
