Free FORM - Connecticut

Please TYPE or PRINT IN INK

Notice to Compensation Commissioner and Employee of Intention to Contest Employee's Right to Compensation Benefits
EMPLOYEE
Name Soc. Sec.# (optional) D.O.B. Address City/Town Zip Code Tel.# State

Rev. 3-17-2006

State of Connecticut Workers' Compensation Commission

43
Date filed in District
(for WCC use only)

WCC File #

INJURY
Date of Injury Date of Death City/Town of Injury State Body Part(s) Nature of Injury Check, if an Occupational Disease or a Repetitive Trauma Zip Code

ATTORNEY OR REPRESENTATIVE OF EMPLOYEE
Name Name of Firm Address City/Town Zip Code Tel.# State

REASON(S) FOR CONTEST -- SIGNATURE
You are hereby notified that the employer/insurer will contest liability to pay compensation benefits to the employee named on this form for the following reason(s) -- SPECIFIC EXPLANATION REQUIRED:

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

INSURER
Claim Number
............................................................................ ............................................................................

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

State Signature Date Name (type or print) Title

Contact Person Tel.#

This notice must be served upon the Commissioner and Employee (or representative, if applicable) by personal presentation or by registered or certified mail. When medical care is the issue for contest, send a copy of this form to the medical provider also. For the protection of both parties, the claimant should note the date when this notice was received and the employer/insurer should keep a copy of this notice with the date it was served.