State of Connecticut Workers’ Compensation Commission Please TYPE or PRINT IN INK and SUBMIT TO THE DISTRICT OFFICE WHERE THE HEARING IS SCHEDULED INFORMAL PRE-FORMAL ** NOT TO BE USED FOR FORMAL HEARINGS HC Rev. 1-17-2007 WCC : File #(s) : Name of Case: Hearing CANCELLATION Request This form MUST be received before 4:30 P.M. or it will not be recorded until the next business day. (claimant) v. All Parties will be REQUIRED TO APPEAR, if this Cancellation Request is not RECEIVED AT LEAST THREE (3) BUSINESS DAYS PRIOR to the scheduled hearing (except for unforeseen emergencies). Contested 36 Forms where benefits are being paid MUST BE AGREED TO IN WRITING by the respondent. Date filed in District . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of Hearing Date of THIS Request (MM/DD/YY) WCC District # (MM/DD/YY) Presiding Commissioner (1-8) (name) Party who initiated Request for this Hearing: Commissioner Claimant / Claimant Rep Respondent / Respondent Rep Other—specify name, firm, or carrier: (for WCC use only) Reason for Requested Cancellation or Continuance Signature of Party Requesting Cancellation or Continuance This request is for: As the party requesting cancellation / continuance of this hearing: Cancellation Continuance ................................................................................... Check the reason for this cancellation / continuance request: Form 36 withdrawn approved by agreement effective: Awaiting additional information commissioner exam deposition employer/respondent’s exam medical reports medicare language review of settlement amount third-party settlement I CONFIRM THAT I HAVE CONTACTED ALL COUNSEL AND PRO SE PARTIES OF RECORD REGARDING MY INTENTION TO SEEK CANCELLATION OR CONTINUANCE. REQUIRED: Attach to this form a sheet listing the name and address of each party notified. ALL COUNSEL AND PRO SE PARTIES OF RECORD: CONSENT — If “Consent” to Cancel the Hearing is not checked here, the Hearing WILL GO FORWARD. Party Unavailable claimant respondent OTHER: claimant’s representative respondent’s representative ................................................................................... Person making THIS request is Claimant Respondent Agrees to pay TP, TT, PPD and/or attorney fees to issue VA, pay medical bills, pay lien, authorize medical treatment, authorize evaluation to accept the claim Claim Not Pursued claim or issue withdrawn requestor does not wish to pursue parties not ready to discuss settlement stipulation documents being prepared Miscellaneous hearing notification incorrect lien paid (check ONE): Claimant’s Representative Respondent Respondent’s Representative OTHER interested party Signature (please specify): Date Name Firm’s Name (if applicable) Address City/Town State Zip Code Tel.# ................................................................................... Date copies (circle ONE) delivered / faxed / mailed: American LegalNet, Inc. www.FormsWorkflow.com