Fill and Sign the Petition for Review Connecticut Form

                                                                                                        (finding & award/dismissal) (ruling on motion) (order) dated                               No If a transcript is requested, please enter the appropriate hearing dates.       No PR STATE OF CONNECTICUT WORKERS' COMPENSATION COMMISSION COMPENSATION REVIEW BOARDPETITION FOR REVIEW Name (Claimant) Date filed in District Date filed with CRB Address City State Zi p V. Name (Employer) Address City State Zi p Name (Insurer) Address City State Zi p The undersigned party (or parties) hereby appeal(s) to the Compensation Review Board from the Commissioner's decision Signature of Appellant or Attorney Date Print Name Print Address A statement of the reasons for the appeal must be filed with the Compensation Review Board within ten (10) days after the filing of this petition, unless the Commissioner extends the time for cause. The statement should allege why the trial Commissioner erred in regard to the law, or in regard to finding or not finding important facts according to the evidence presented at the hearing. If Appellant claims the Commissioner's finding of facts is incorrect, a motion to correct the finding should be filed within two (2) weeks after such finding has been filed, unless the Commissioner extends such time for cause. With such a motion must be filed such parts or all of the transcript of the evidence as Appellant relies on. For this purpose a transcript must be requested. A transcript is hereby requested for this appeal. Check one: Yes The Appellant may also file a motion to submit additional evidence or testimony, together with the reasons for failure to present it in the hearing. A motion will be filed asking permission to submit additional evidence or testimony. Check one: Ye s An original and five (5) copies of this form must be completed and filed with a district office, preferably where the award, order/finding or decision you're appealing was rendered within ten (10) days after its issuance, or the appeal will be dismissed. Note. Parties should consult Sec. 31-301 C.G.S. and any other statutes and Administrative Regulations pertaining to the appeal process. Rev. 3/16/98