Notice of Intention to Reduce or Discontinue Payments Please TYPE or PRINT IN INK State of Connecticut Workers Compensation Commission Rev. 7-13-2009 IMPORTANT 36 Date filed in District (for WCC use only) WCC File # You are hereby notified that the employer/insurer intends to REDUCE OR DISCONTINUE your compensation payments on (date) for the following reason(s): (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: q q q q (Employer/insurer to check appropriate box.) 2 Norwich 1 Hartford 3 New Haven 4 Bridgeport 700 State Street 55 Main Street 999 Asylum Avenue (860) 566-4154 (203) 789-7512 (860) 823-3900 350 Fairfield Avenue (203) 382-5600 q q q q 5 Waterbury 7 Stamford 6 New Britain 8 Middletown 55 West Main Street 233 Main Street 111 High Ridge Road (203) 596-4207 (203) 325-3881 (860) 827-7180 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 Name D.O.B. (required) Address City/Town Zip Code Tel.# State INJURY Date of Injury City/Town of Injury State Body Part Nature of Injury Cause of Injury Zip Code ATTORNEY OR REPRESENTATIVE OF EMPLOYEE Name Name of Firm Address City/Town Zip Code Tel.# State INSURER Claim Number Voluntary Agreement Issued? Name Address City/Town Zip Code State ............................................................................ q YES q NO EMPLOYER Name Address City/Town Zip Code Tel.# State ............................................................................ Contact Person 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 CLAIMANTS ATTORNEY. American LegalNet, Inc. www.FormsWorkFlow.com