Hearing Request {HR}

Hearing Request Informal Pre-Formal Disfigurement / Scar -- Surgery Date(s): Please TYPE or PRINT IN INK and SEND A COPY OF THIS REQUEST TO ANY OTHER INTERESTED PARTY(IES) Rev. 3-17-2006 State of Connecticut Workers' Compensation Commission HR Date filed in District (for WCC use only) WCC File # I hereby notify the Workers' Compensation Commission of my request for the following hearing: Formal Stip Approval 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 (required): INJURED WORKER Name Soc. Sec.# (optional) 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 City/Town State Tel.# EMPLOYER Name Address City/Town Zip Code Tel.# State Zip Code ADDITIONAL INTERESTED PARTIES FOR NOTIFICATION -- List: INSURANCE Policy Insurer Name Policy No. Address City/Town Zip Code Tel.# State Eff. Date ............................................................................ Administrator Name Contact Person Address City/Town Zip Code Tel.# State SIGNATURE OF REQUESTING PARTY 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 that it is improper to request a hearing without first trying to resolve the issues with the other party. I am the (check ONE): injured worker or representative insurance company or representative additional interested party (please specify): State Tel.# Signature Date ............................................................................ Attorney for Insurance Carrier Name of Firm Address City/Town Zip Code American LegalNet, Inc. www.FormsWorkflow.com