Free FORM - Connecticut

IMPORTANT
State of Connecticut Workers' Compensation Commission

36
Date filed in District
(for WCC use only)

Notice of Intention to Reduce or Discontinue Payments
Please TYPE or PRINT IN INK

You are hereby notified that the employer/insurer intends to REDUCE OR DISCONTINUE your compensation payments on for the following reason(s):
(date)

(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:
(Employer/insurer to check appropriate box.)

1 -- Hartford 2 -- Norwich 3 -- New Haven 4 -- Bridgeport

999 Asylum Avenue 55 Main Street 700 State Street 350 Fairfield Avenue

(860) 566-4154 (860) 823-3900 (203) 789-7512 (203) 382-5600

5 -- Waterbury 6 -- New Britain 7 -- Stamford 8 -- Middletown

55 West Main Street 233 Main Street 111 High Ridge Road 90 Court Street

Rev. 10-1-2007

WCC File #

(203) 596-4207 (860) 827-7180 (203) 325-3881 (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 Soc. Sec.# (optional) D.O.B. 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? YES NO

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

Name Address City/Town Zip Code
............................................................................

EMPLOYER
Name Address City/Town Zip Code Tel.# State

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 CLAIMANT'S ATTORNEY.