Please TYPE or PRINT IN INK 43 Rev. 3-17-2006 State of Connecticut Workers’ Compensation Commission WCC File # Notice to Compensation Commissioner and Employee of Intention to Contest Employee’s Right to Compensation Benefits Date filed in District (for WCC use only) EMPLOYEE INJURY Name Date of Injury Soc. Sec.# (optional) Date of Death D.O.B. City/Town of Injury Address State City/Town Zip Code State Tel.# Nature of Injury Check, if an Occupational Disease or a Repetitive Trauma ATTORNEY OR REPRESENTATIVE OF EMPLOYEE Name REASON(S) FOR CONTEST — SIGNATURE Name of Firm You are hereby notified that the employer/insurer will contest liability to pay compensation benefits to the employee named on this form for the following reason(s) — SPECIFIC EXPLANATION REQUIRED: Address City/Town Zip Code Zip Code Body Part(s) State Tel.# EMPLOYER Name Address City/Town Zip Code State Tel.# INSURER Claim Number ............................................................................ ............................................................................ Name Address City/Town State Zip Code Signature ............................................................................ Date Contact Person Name (type or print) Tel.# Title This notice must be served upon the Commissioner and Employee (or representative, if applicable) by personal presentation or by registered or certified mail. When medical care is the issue for contest, send a copy of this form to the medical provider also. For the protection of both parties, the claimant should note the date when this notice was received and the employer/insurer should keep a copy of this notice with the date it was served. American LegalNet, Inc. www.FormsWorkflow.com