Please TYPE or PRINT IN INK PFR Rev. 3-17-2006 State of Connecticut Workers’ Compensation Commission WCC File # Date filed with CRB (for WCC use only) Petition for Review Date filed in District (for WCC use only) Compensation Review Board Parties should consult Section 31-301 C.G.S. and any other statutes and Administrative Regulations pertaining to the appeal process. APPEAL CLAIMANT The undersigned party(ies) hereby appeal(s) to the Compensation Review Board from the Commissioner’s: Name of Claimant finding & award/dismissal ruling on motion Address City/Town order dated: State DIRECTIONS AND REQUIREMENTS EMPLOYER An original and five (5) copies of this form must be completed and filed with a district office, preferably where the award, order/ finding, or decision which you are appealing was rendered, within twenty (20) days after its issuance, or the appeal will be dismissed. Name of Employer Reasons of Appeal [See Sec. 31-301-2] A statement of the reasons for the appeal must be filed with the Compensation Review Board within ten (10) days after the filing of this petition, unless the Chairman extends such time for cause. The reasons should state why the trial Commissioner erred in regard to the law, or in regard to finding or not finding important facts according to the evidence presented at the hearing. City/Town Correction of Finding [See Sec. 31-301-4] If Appellant claims the Commissioner’s factual findings are incorrect, a motion to correct the findings should be filed within two (2) weeks after such findings have been filed, unless the Commissioner extends such time for cause. With the motion must be filed the portions of the evidence and/or such portions or all of the transcript upon which the Appellant relies; and, for this purpose a transcript must be requested. Zip Code Name of Insurer Address State Zip Code INSURER Address City/Town State Zip Code Are you requesting a transcript for this appeal? Yes No If a transcript is requested, please enter the appropriate formal hearing date(s): SIGNATURE OF APPELLANT OR ATTORNEY Signature Additional Evidence [See Sec. 31-301-9] The Appellant may also file a motion to submit additional evidence or testimony, together with the reasons for failure to present it in the hearing. Name of Appellant or Attorney Will you be filing a motion asking permission to submit additional evidence or testimony? Date City/Town Yes No Address State Zip Code American LegalNet, Inc. www.FormsWorkflow.com