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Get Please Type Or Print In Ink Mandatory Notice To Dependents By Employer Or Insurer To Be Filed Upon

Icut Workers Compensation Commission WCC File #(s) Date filed in District Pursuant to Section 31-306b C.G.S., this notice must be sent by registered or certified mail to the last address to which the injured employee s workers compensation benefit checks were mailed. (for WCC use only) NOTIFICATION OF ELIGIBILITY FOR DEATH BENEFITS To the Dependents of born on (name of employee) of (date of birth) who was injured in (employee s address) (town of injury) We have been notified.

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