Notice To Dependents {98}

Please TYPE or PRINT IN INK Rev. 1-31-2005 State of Connecticut Workers' Compensation Commission 98 Date filed in District Mandatory Notice to Dependents by Employer or Insurer to be filed upon Death of Employee who is receiving Weekly Disability Benefits 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. A copy of this form must also be sent by the Employer or Insurer to the Workers' Compensation Commissioner. (for WCC use only) Notification of Eligibility for Death Benefits To the Dependents of (name of employee) of (employee's address) We have been notified that the above-named employee may have died as a consequence of an injury arising from his or her employment. Our records indicate that he or she was injured on (date of injury) and was receiving benefits under Connecticut's Workers' Compensation Act. As dependents, you may be eligible for benefits under Section 31-306 of the Connecticut General Statutes. Any dependent who requests such benefits must file a written notice of claim with the Connecticut Workers' Compenstion Commission. The notice must be filed so as to comply with the time limits set forth in Section 31-294c of the Connecticut General Statutes. Failure to comply with the notice requirements of Section 31-294c may result in forfeiture of any benefits to which a dependent may be entitled. In the event you have any questions relating to the above, we urge you to call the Workers' Compensation Commission at 1-800-223-9675 or consult with your legal advisor. Employer or Insurer SENDING Notice This Notice is being SENT BY: Employer or Insurer Name Address City/Town State Zip Code Signature Print Name Date Sent Title American LegalNet, Inc. www.USCourtForms.com