State of Connecticut Workers Compensation Commission
Please TYPE or PRINT IN INK
WCC File # Insurer #
42
(for WCC use only)
Physicians Permanent Impairment Evaluation
The Form 42 should be mailed to ALL parties (employee, insurer, attorneys).
Rev. 4-30-2009
Date filed in District
EMPLOYEE
Name D.O.B. Address
EMPLOYER
Name
INJURY
Date of Injury
City/Town Zip Code Tel.#
State
City/Town of Injury State Zip Code
EVALUATION
IMPORTANT Use a separate Form 42 for EACH body part! Connecticut Statutes do NOT recognize whole person ratings [Section 31-308(b)].
Body Part
Percentage of Permanent Loss (or Loss of Use)
LIMB is ..........................................
q q q
LEFT .................
q q q
RIGHT
Maximum Medical Improvement Exam Date
HAND, ARM, or THUMB is ...........
MASTER ...........
MINOR
Which standards were utilized in your evaluation? (AMA Edition # or Other Source)
EYE is ...........................................
LEFT * ..............
RIGHT *
* Indicate:
q
complete and permanent loss of sight
q
reduction of sight to one-tenth (1/10) or less of normal vision
CONNECTICUT-LICENSED PHYSICIAN SIGNATURE
Name Address City/Town State Zip Code Tel. #
Signature of Connecticut-Licensed Physician Print Name of Connecticut-Licensed Physician
Date