Filing Status And Exemption Form {1A}

<document>WCC FILE #State of ConnecticutWorkers' Compensation Commission FILING STATUS AND EXEMPTION FORM THIS FORM MUST BE EXECUTED IN EVERY CASE OFCOMPENSABLE DISABILITY, FOR INJURIES OCCURRING ON OR AFTEROCTOBER 1, 1991Name:SS#:Address:In order for this company to determine your weekly benefit rate, as per Public Act 93-228, an Act concerning comprehensive Workers' Compensation reform, we need the following information:1.There are four (4) filing statuses provided. You must select one, based upon your IRS filing status on the date of your injury and the position you took in filing your prior year's Federal and State Tax Returns. (i.e. D.O.I. 6/15/96, last tax return 12/31/95)A. SingleB. Head of HouseholdC. Married filing jointlyD. Married, filing separately2.How many exemptions (include yourself) did you list on your last Federal and State Tax Returns? 3.Check all appropriate boxes:legally blindspouse -65 years of age or olderspouse -legally blind65 years of age or older4.List name (yourself first), date of birth and relationship to you for all exemptions listed on your last Federal and State Tax Returns: (Question #2 above):NameBirth DateRelationship1. SELF2. 3. 4. 5. 6. 5.IMPORTANT: To be certain that you receive all the benefits to which you are entitled please provide the following information if you were engaged in any other employment at the time of your injury or are currently engaged in any other employment. If you have no other employment insert the word none .Other Employers: Names Addresses Weekly hours: Weekly wages: Date of hire: Are you currently working:Type of Work Performed:6.This form must be completed in its entirety. Any person who intentionally misrepresents or fails to disclose any material fact related to a claimed injury may be guilty of a felony.DATEEMPLOYEE'S SIGNATURE 2000 © American LegalNet, Inc.</document>