Fill and Sign the Hearing Request Connecticut Form

WCC FILE #                   Soc. Sec. #             Name of Finn:       Address:       Address:       City, St., Zip:       City, St., Zip:       Tel. # -                         Address:       Address:       City, St., Zip:       City, St., Zip:                   Date of Injury:             Town of Injury:             Name of Finn:       Body Part:       Address:       City, St., Zip:                   Informal Scar Date of Surgery : Pre-Formal Stip Approval Emergency       Repetitive Trauma?       Formal             injured worker or representative insurance company or representative specify)       additional interested party (please Date:       HR State of Connecticut Workers' Compensation Commission Hearing Request Injured Worker Information (Please Print or Type in Ink) Attorney or Representative of Injured Worker Name: Name: D.O.B. Tel. #- Employer Information Workers' Compensation Insurance Information Name: Name: Tel. #- Tel. #- Injury Information Attorney for Insurance Company Name: Zip: Describe injury and how it happened: Tel. #- Type of Hearing You Are Requesting: Occupational Illness Reason for hearing (if emergency, please explain why): Additional Interested Parties for Notification: As the party requesting the hearing, I confirm that I have tried to resolve the above issues by telephone or written communication with the other party. I understand it is improper to request a hearing without first trying to resolve the issues with the other party. I am the (check one): Your Signature: Rev. 3/16/98