Notification Of Appearance
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Notification Of Appearance Form. This is a Connecticut form and can be use in Workers Compensation.
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Tags: Notification Of Appearance, NOA, Connecticut Workers Compensation,
NOA
Rev. 3-17-2006
State of Connecticut
Workers’ Compensation Commission
Please TYPE or PRINT IN INK
WCC File #
Notification of Appearance
I hereby notify the Workers’ Compensation Commission
Date filed in District
District Office regarding the following matter:
(1st -8th)
CLAIMANT
v.
RESPONDENT
WCC File # (ONE only)
Date of Injury
(for WCC use only)
REPRESENTATION
Your Name
Name of Firm
Address
City/Town
State
Telephone Number
Zip Code
Fax Number
APPEARANCE
1 — CHECK AT LEAST ONE (1) BOX below and provide the appropriate information for any box(es) you check.
I represent the CLAIMANT
I represent the DEPENDENT SURVIVOR
I represent the INSURER
. . . FOR THE EMPLOYER
. . . FOR THE POLICY PERIOD (MM/DD/YY - MM/DD/YY)
I represent the EMPLOYER (only)
I represent the EMPLOYER FOR § 31-290a CLAIM (only)
I represent the MEDICAL PROVIDER
I represent ANOTHER PARTY (please specify)
2 — CHECK ANY APPLICABLE BOX(ES) below and provide the appropriate information for any box(es) you check.
I am appearing in lieu of
I am appearing in addition to
3 — DATE AND SIGN this form.
Date
Signature
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