Free FORM - Connecticut

Hearing Request
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Informal

Please TYPE or PRINT IN INK and SEND A COPY OF THIS REQUEST TO ANY OTHER INTERESTED PARTY(IES)

Rev. 4-30-2009

State of Connecticut Workers Compensation Commission

WCC File #

HR
(for WCC use only)

Date filed in District

I hereby notify the Workers Compensation Commission of my request for the following hearing:

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Pre-Formal

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Formal

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Stip Approval

Disfigurement / Scar Surgery Date(s):
For injuries occurring ON OR AFTER July 1, 1993, disfigurement/scar benefits are available ONLY for disfigurements or scars on the face, head, neck, or any other area of the body that handicaps the employee from obtaining or continuing to work. [See Sec. 31-308(c)]

Reason(s) for the requested hearing AND supporting documents are required:

INJURED WORKER
Name D.O.B. Address City/Town Zip Code Tel.# State

INJURY
Date of Injury City/Town of Injury State Body Part Zip Code

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

EMPLOYER
Name Address City/Town Zip Code Tel.#

INSURANCE
Policy Insurer Name Policy No. Address City/Town Zip Code Tel.# State Eff. Date

ADDITIONAL INTERESTED PARTIES FOR NOTIFICATION List:

REQUIRED
You MUST attach to this form a list of the names and addresses of each party you have contacted in your attempt to resolve this issue. As the party requesting the hearing, I CONFIRM THAT I HAVE CONTACTED ALL COUNSEL AND PRO SE PARTIES OF RECORD BY TELEPHONE OR WRITTEN COMMUNICATION AND HAVE BEEN UNABLE TO RESOLVE THE ABOVE ISSUES. I understand that it is improper to request a hearing without first trying to resolve the issues with the other party.
I am the (check ONE):

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

Administrator Name Contact Person Address City/Town Zip Code Tel.# State

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

Attorney for Insurance Carrier Name of Firm Address City/Town Zip Code Tel.# State

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injured worker or representative insurance company or representative additional interested party (please specify):

Signature

Date