Free FORM - Connecticut

State of Connecticut Workers' Compensation Commission
Please TYPE or PRINT IN INK and SUBMIT TO THE DISTRICT OFFICE WHERE THE HEARING IS SCHEDULED

Rev. 1-17-2007

HC

WCC

:

INFORMAL

PRE-FORMAL

** NOT TO BE USED FOR FORMAL HEARINGS

File #(s) : Name of Case:

Hearing CANCELLATION Request
This form MUST be received before 4:30 P.M. or it will not be recorded until the next business day. All Parties will be REQUIRED TO APPEAR, if this Cancellation Request is not RECEIVED AT LEAST THREE (3) BUSINESS DAYS PRIOR to the scheduled hearing (except for unforeseen emergencies). Contested 36 Forms where benefits are being paid MUST BE AGREED TO IN WRITING by the respondent.
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(claimant)

v.

Date filed in District

Date of Hearing
(MM/DD/YY)

Date of THIS Request
(MM/DD/YY)

WCC District #
(1-8)

Presiding Commissioner
(name)

Party who initiated Request for this Hearing: Commissioner Claimant / Claimant Rep Respondent / Respondent Rep
(for WCC use only)

Other--specify name, firm, or carrier:

Reason for Requested Cancellation or Continuance
This request is for: Cancellation Continuance

Signature of Party Requesting Cancellation or Continuance
As the party requesting cancellation / continuance of this hearing: I CONFIRM THAT I HAVE CONTACTED ALL COUNSEL AND PRO SE PARTIES OF RECORD REGARDING MY INTENTION TO SEEK CANCELLATION OR CONTINUANCE. REQUIRED: Attach to this form a sheet listing the name and address of each party notified. ALL COUNSEL AND PRO SE PARTIES OF RECORD:
CONSENT -- If "Consent" to Cancel the Hearing is not checked here, the Hearing WILL GO FORWARD.

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

Check the reason for this cancellation / continuance request:

Form 36
withdrawn approved by agreement effective:

Awaiting
additional information commissioner exam deposition employer/respondent's exam medical reports medicare language review of settlement amount third-party settlement

Party Unavailable
claimant respondent OTHER: claimant's representative respondent's representative
...................................................................................

Person making THIS request is Claimant Respondent

(check ONE):

Claimant's Representative Respondent's Representative
(please specify):

Respondent Agrees
to pay TP, TT, PPD and/or attorney fees to issue VA, pay medical bills, pay lien, authorize medical treatment, authorize evaluation to accept the claim

OTHER interested party

Signature Name Firm's Name Address City/Town Zip Code
(if applicable)

Date

Claim Not Pursued
claim or issue withdrawn requestor does not wish to pursue parties not ready to discuss settlement stipulation documents being prepared

State Tel.#

Miscellaneous
hearing notification incorrect lien paid

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

Date copies

(circle ONE)

delivered / faxed / mailed: