%PDF-1.7
%
1 0 obj
<>
endobj
2 0 obj
<>
endobj
3 0 obj
<>
endobj
4 0 obj
<>
endobj
5 0 obj
<>stream
2021-07-13T09:48:32-04:00
2021-07-13T10:00:36-04:00
2021-07-13T10:00:36-04:00
Adobe InDesign CS6 (Windows)
uuid:bfd15863-50a7-4c43-b6cd-9c787a742579
xmp.did:5042D85BD1A2E711B4DCA4C3BB4BEB9B
xmp.id:89EF0D43E0E3EB119F2FF06B91C90C3A
proof:pdf
converted
from application/x-indesign to application/pdf
Adobe InDesign CS6 (Windows)
/
2021-07-13T09:48:32-04:00
xmp.iid:88EF0D43E0E3EB119F2FF06B91C90C3A
xmp.did:5042D85BD1A2E711B4DCA4C3BB4BEB9B
xmp.did:5042D85BD1A2E711B4DCA4C3BB4BEB9B
default
application/pdf
FORM: Notice to Employees (Revised 10-01-2017)
WCC
Connecticut Workers' Compensation Commission Agency Publications
Adobe PDF Library 10.0.1
False
1
1.1
endstream
endobj
6 0 obj
<>
endobj
7 0 obj
<>
endobj
8 0 obj
</Filter/Adobe.PPKLite/M(D:20210713100036-04'00')/Name(ARE Acrobat Product v8.0 P23 0002337)/Prop_Build<>/Filter<>/PubSec<>>>/Reference[<>/Type/SigRef>>]/SubFilter/adbe.pkcs7.detached/Type/Sig>>>>/Type/Catalog/ViewerPreferences<>>>
endobj
9 0 obj
<>
endobj
10 0 obj
<>/Font<>>>/Fields[ 13 0 R 14 0 R 15 0 R 17 0 R 18 0 R 19 0 R 16 0 R 20 0 R 24 0 R 28 0 R 30 0 R 31 0 R 32 0 R 29 0 R 33 0 R 34 0 R 36 0 R 37 0 R 38 0 R 35 0 R 39 0 R ]/SigFlags 2>>
endobj
11 0 obj
<>/Font<>/ProcSet[/PDF/Text/ImageB]/XObject<>>>/Rotate 0/TrimBox[ 0 0 612 1008]/Type/Page>>
endobj
12 0 obj
[ 13 0 R 14 0 R 15 0 R 16 0 R 17 0 R 18 0 R 19 0 R 20 0 R 24 0 R 28 0 R 29 0 R 30 0 R 31 0 R 32 0 R 33 0 R 34 0 R 35 0 R 36 0 R 37 0 R 38 0 R 39 0 R ]
endobj
13 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Rect[ 65.5726 728.177 547.229 746.831]/Subtype/Widget/T(Employer-Name)/Type/Annot/V(United Parcel Service)>>
endobj
14 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Rect[ 103.789 532.334 546.034 550.988]/Subtype/Widget/T(Insurer-Name)/Type/Annot/V(Liberty Mutual Insurance)>>
endobj
15 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Rect[ 123.879 512.732 347.126 531.385]/Subtype/Widget/T(Insurer-Address)/Type/Annot/V(P.O. Box 3634)>>
endobj
16 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Rect[ 412.208 512.859 545.476 531.513]/Subtype/Widget/T(Insurer-Telephone)/Type/Annot/V(800-300-4472)>>
endobj
17 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Rect[ 128.143 492.666 346.928 511.32]/Subtype/Widget/T(Insurer-City-Town)/Type/Annot/V(Bala Cynwyd)>>
endobj
18 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Q 1/Rect[ 377.319 492.781 436.969 511.435]/Subtype/Widget/T(Insurer-State)/Type/Annot/V(PA)>>
endobj
19 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Q 1/Rect[ 487.669 492.666 546.575 511.32]/Subtype/Widget/T(Insurer-Zip-Code)/Type/Annot/V(19004)>>
endobj
20 0 obj
<>/N<>>>/AS/Yes/DA(/ZaDb 10 Tf 0 g)/F 4/FT/Btn/MK<>/P 11 0 R /Rect[ 210.509 459.491 222.035 471.389]/Subtype/Widget/T(Yes)/Type/Annot/V/Yes>>
endobj
21 0 obj
<>/Subtype/Form/Type/XObject>>stream
H*2T0T3523R
E\\y\ B.THR!*$U` X
endstream
endobj
22 0 obj
<>/Subtype/Form/Type/XObject>>stream
x337402VH2P0P043523
E\i\ x
endstream
endobj
23 0 obj
<>/Subtype/Form/Type/XObject>>stream
HL
0U(m K ^}z@(T
=,q@'5)749:W|?0`
endstream
endobj
24 0 obj
<>/N<>>>/AS/Off/DA(/ZaDb 10 Tf 0 g)/F 4/FT/Btn/MK<>/P 11 0 R /Rect[ 253.92 459.677 265.446 471.575]/Subtype/Widget/T(No)/Type/Annot>>
endobj
25 0 obj
<>/Subtype/Form/Type/XObject>>stream
H*2T0T352Q
E\\y\F@B.THR!*o*
0
endstream
endobj
26 0 obj
<>/Subtype/Form/Type/XObject>>stream
x337402VH2P0P043523
E\i\ x
endstream
endobj
27 0 obj
<>/Subtype/Form/Type/XObject>>stream
HD
0U(m%(쳄ԺXBj3vN}+5)WT9:|Ӊ
endstream
endobj
28 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Rect[ 123.359 412.233 346.606 430.887]/Subtype/Widget/T(WCC-District-Address)/Type/Annot/V(350 Fairfield Avenue)>>
endobj
29 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Rect[ 412.092 413.077 545.733 431.73]/Subtype/Widget/T(WCC-District-Telephone)/Type/Annot/V(203-382-5600)>>
endobj
30 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Rect[ 127.623 391.167 346.408 409.821]/Subtype/Widget/T(WCC-District-City-Town)/Type/Annot/V(Bridgeport)>>
endobj
31 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Q 1/Rect[ 376.799 391.283 436.448 409.936]/Subtype/Widget/T(WCC-District-State)/Type/Annot/V(CT)>>
endobj
32 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Q 1/Rect[ 487.149 391.167 546.055 409.821]/Subtype/Widget/T(WCC-District-Zip-Code)/Type/Annot/V(06604)>>
endobj
33 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Rect[ 153.984 212.82 546.034 231.473]/Subtype/Widget/T(Employer-PA17-141-Name)/Type/Annot/V(United Parcel Service--Attn: Legal SOP)>>
endobj
34 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Rect[ 123.879 192.217 347.126 210.87]/Subtype/Widget/T(Employer-PA17-141-Address)/Type/Annot/V(55 Glenlake Parway NE)>>
endobj
35 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Rect[ 412.22 192.393 545.488 211.047]/Subtype/Widget/T(Employer-PA17-141-Telephone)/Type/Annot/V(860-493-1589)>>
endobj
36 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Rect[ 128.143 171.151 346.928 189.805]/Subtype/Widget/T(Employer-PA17-141-City-Town)/Type/Annot/V(Atlanta)>>
endobj
37 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Q 1/Rect[ 377.319 171.266 436.969 189.92]/Subtype/Widget/T(Employer-PA17-141-State)/Type/Annot/V(GA)>>
endobj
38 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Q 1/Rect[ 486.669 171.151 545.575 189.805]/Subtype/Widget/T(Employer-PA17-141-Zip-Code)/Type/Annot/V(30328)>>
endobj
39 0 obj
<>/DA(/Helv 10 Tf 0 g)/F 4/FT/Tx/Ff 12582912/MK<<>>/P 11 0 R /Q 1/Rect[ 128.47 53.8493 321.604 72.503]/Subtype/Widget/T(Date-Posted)/Type/Annot/V(08/11/2021)>>
endobj
40 0 obj
[ 41 0 R 42 0 R 43 0 R 44 0 R 45 0 R 46 0 R 47 0 R 48 0 R ]
endobj
41 0 obj
<>stream
HT]k0}ׯ ,-C04ƨm!k&i+KFbl_stνWfQ|2bcGd2ry!2g49XQp\11Wܥ];x$!U)|CS9xZujm\|JU{b}oSΙk
H,,˩}Y`hPiA%˫jFQԾR35eE8Axnc_57Pm`F:_R|N$^1&.uΘ*ueYs <[z\Jy\v*?Ui*