Fill and Sign the Notice of Intention to Discontinue Connecticut Form

WCC FILE #       DISTRICT       compensation to the employee named below on       EMPLOYEE:       DATE OF INJURY:       SOC. SEC. #-             TOWN OF INJURY:       ADDRESS:       PART OF BODY:                         NATURE OF INJURY:       CAUSE OF INJURY:             EMPLOYER:       NAME:       ADDRESS:                         ADDRESS:                               CONTACT PERSON:       TEL. #-       DATE MAILED:       usual light selected work       There will/will not (circle one) be permanent loss, or loss of use of                         FORM 36 State of Connecticut Workers' Compensation Commission Form Notice To Compensation Commissioner And Employee Of Intention To Discontinue Or Reduce Payments (Please Type or Print in Ink) Important Information: • Within ten days of receipt of this notice, the employee may request a hearing by the Compensation Commissioner on the discontinuance or reduction set forth in this notice. • If otherwise proper, this notice will be approved unless contested. If contested, this notice will not be approved without proof of receipt of notice. Instructions For The Insurer: 1. Two copies of this notice must be sent by certified mail, one filed with the Commissioner and one with the employee. If the claimant is represented by an attomey, a copy should be sent to the claimant's attomey as well. 2. If the employee is returned to light or selected duty work, please attach the procedure/limitations for such work to all copies. You are hereby notified that the undersigned employer intends to discontinue or reduce the payments of for the following reason, to wit. (Please specify) (date) Employee Information Injury Information D.O.B. TOWN STATE ZIP TEL. #- Employer Information Insurance Carrier Information TOWN STATE ZIP TOWN STAT E ZIP TEL. #- FOR PHYSICIAN'S USE ONLY I hereby certify that the above named employee is able to return to (check one) on (date ) (part of body ) Print Physician's name Signature of CT Licensed Physician Date ****Attach supporting medical documentation**** Rev. 7/14/99