Free FORM - Connecticut

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Rev. 3-17-2006

State of Connecticut Workers' Compensation Commission

44
Date filed in District
(for WCC use only)

WCC File #

Order to Second Injury Fund in Cases of Concurrent Employment
The Insurer / Payor shall furnish the Treasurer such documents as is necessary to verify payments for which it is seeking reimbursement.

ORDER
Pursuant to C.G.S. Section 31-310, the Treasurer of the State of Connecticut is ordered to reimburse the subject Insurer / Payor for the prorated share it has expended under Voluntary Agreement approved on
(date)

CLAIMANT
Name Soc. Sec.# (optional) D.O.B. Address City/Town Zip Code Tel.# State

for the captioned injury. The Insurer / Payor attests that it has paid the complete adjusted total weekly benefit as agreed to on the subject Voluntary Agreement and now seeks reimbursement for the prorated share in the amount of $ for the weekly periods enumerated below, check to be made payable to:

INJURY
Date of Injury

EMPLOYER
Name Address City/Town State Tel.#

Temporary Total Benefits
from

= $
to

Zip Code

INSURER / PAYOR
Name Address City/Town State Tel.#

Temporary Partial Benefits = $
from to

Permanent Partial Benefits = $
from to

Zip Code

............................................................................

Contact Person

The Form 44 will NOT be processed without both signatures:

WORKERS' COMPENSATION COMMISSION APPROVAL

Signature of INSURER / PAYOR Representative

Date (MM/DD/YY) Date (MM/DD/YY) Sent to SIF

Signature of SECOND INJURY FUND Representative

Date (MM/DD/YY)
(for WCC use only)