Order To Second Injury Fund In Cases Of Concurrent Employment {44}

State of Connecticut Workers Compensation Commission 44 Please TYPE or PRINT IN INK . 3-5-2004Rev WCC File # Date filed in District Order to Second Injury Fund in Cases of Concurrent Employment The Insurer / Payor shall furnish the Treasurer such documents as is necessary to verify payments for which it is seeking reimbursement. (for WCC use only)Order Claimant Name Pursuant to C.G.S. Section 31-310, the Treasurer of the Soc. Sec.# (optional) State of Connecticut is ordered to reimburse the subject Insurer / Payor for the prorated share it has expended D.O.B. under Voluntary Agreement approved on Address City/Town State (date) for the captioned injury. Zip Code Tel.# Injury The Insurer / Payor attests that it has paid the complete adjusted total weekly benefit as agreed to on the subject Date of Injury Voluntary Agreement and now seeks reimbursement for the prorated share in the amount of Employer $ Name for the weekly periods enumerated below, check to be made payable to: Address City/Town State Zip Code Tel.# Temporary Total Benefits= $ Insurer / Payor from to Name Temporary Partial Benefits= $ Address City/Town State from to Zip Code Tel.# Permanent Partial Benefits= $ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contact Person from to Workers Compensation Commission Approval The Form 44 will NOT be processed without both signatures: Signature of INSURER / PAYOR Representative Date (MM/DD/YY) Date (MM/DD/YY) Sent to SIF Signature of SECOND INJURY FUND RepresentativeDate (MM/DD/YY) (for WCC use only)