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State of Connecticut Workers' Compensation Commission
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98
Date filed in District

Mandatory Notice to Dependents by Employer or Insurer to be filed upon Death of Employee who is receiving Weekly Disability Benefits
Pursuant to Section 31-306b C.G.S., this notice must be sent by registered or certified mail to the last address to which the injured employee's workers' compensation benefit checks were mailed.

Rev. 4-29-2008

WCC File #(s)

(for WCC use only)

NOTIFICATION OF ELIGIBILITY FOR DEATH BENEFITS To the Dependents of
(name of employee)

born on
(date of birth)

of
(employee's address)

who was injured in
(town of injury)

We have been notified that the above-named employee may have died as a consequence of an injury arising from his or her employment. Our records indicate that he or she was injured on
(date of injury)

and was receiving benefits under Connecticut's Workers' Compensation Act. As dependents, you may be eligible for benefits under Section 31-306 of the Connecticut General Statutes. Any dependent who requests such benefits must file a written notice of claim that complies with the time limits set forth in Section 31-294c of the Connecticut General Statutes. Such notice of claim (Form 30D) may be filed with the Connecticut Workers' Compensation Commission or the Employer. Failure to comply with the notice requirements of Section 31-294c may result in forfeiture of any benefits to which you may be entitled. In the event you have any questions relating to the above, we urge you to call the Workers' Compensation Commission at 1-800-223-9675 or consult with your legal advisor. THIS NOTICE IS BEING SENT BY (check one)
Employer Name Address City/Town State Zip Code

EMPLOYER

INSURER

Insurer Name Address City/Town State Zip Code

Signature Print Name

Date Sent Title