Hearing Request Please TYPE or PRINT IN INK and SEND A COPY OF THIS REQUEST TO ANY OTHER INTERESTED PARTY(IES) HR Rev. 4-30-2009 State of Connecticut Workers’ Compensation Commission WCC File # Date filed in District I hereby notify the Workers’ Compensation Commission of my request for the following hearing: q q Informal q q Pre-Formal q Formal Stip Approval Disfigurement / Scar — Surgery Date(s): For injuries occurring ON OR AFTER July 1, 1993, disfigurement/scar benefits are available ONLY for disfigurements or scars on the face, head, neck, or any other area of the body that handicaps the employee from obtaining or continuing to work. [See Sec. 31-308(c)] Reason(s) for the requested hearing AND supporting documents are required: (for WCC use only) INJURED WORKER INJURY Name Date of Injury D.O.B. City/Town of Injury Address State City/Town Zip Code State Tel.# Body Part ATTORNEY OR REPRESENTATIVE OF INJURED WORKER Name EMPLOYER Name of Firm Name Address Address City/Town Zip Code Zip Code State Tel.# City/Town State Zip Code Tel.# ADDITIONAL INTERESTED PARTIES FOR NOTIFICATION — List: INSURANCE Policy Insurer Name Policy No. Eff. Date REQUIRED Address City/Town Zip Code State Tel.# ............................................................................ Administrator Name Contact Person Address City/Town Zip Code State Tel.# ............................................................................ As the party requesting the hearing, I CONFIRM THAT I HAVE CONTACTED ALL COUNSEL AND PRO SE PARTIES OF RECORD BY TELEPHONE OR WRITTEN COMMUNICATION AND HAVE BEEN UNABLE TO RESOLVE THE ABOVE ISSUES. I understand that it is improper to request a hearing without first trying to resolve the issues with the other party. I am the (check ONE): q q q Attorney for Insurance Carrier Name of Firm Address City/Town Zip Code You MUST attach to this form a list of the names and addresses of each party you have contacted in your attempt to resolve this issue. injured worker or representative insurance company or representative additional interested party (please specify): State Tel.# Signature Date American LegalNet, Inc. www.FormsWorkFlow.com