Newly-Updated 36, 42, and 98 Forms


TO: Commissioners, District Administrators, Self-Insureds, Insurance Carriers, Attorneys, Unions, Medical Practitioners, Legal Advisory Panel, Medical Advisory Panel, and Advisory Board Members
FROM: John A. Mastropietro, Chairman
DATE: February 3, 2005
RE: Newly-Updated 36, 42, and 98 Forms


I am pleased to announce that the Commission has recently revised and redesigned the Form 36 ("Notice to Employee and Compensation Commissioner of Intention to Discontinue or Reduce Payments"), the Form 42 ("Physician's Permanent Impairment Evaluation"), and the Form 98 ("Mandatory Notice to Dependents by Employer or Insurer to be filed upon Death of Employee who is receiving Weekly Disability Benefits").

You may obtain copies of these newly-updated forms from our website at:

or by requesting hard copies from our Education Services office at:

Workers' Compensation Commission
Education Services
21 Oak Street, 4th Floor
Hartford, CT 06106-8011

Phone: (860) 493-1500
Fax: (860) 247-1361

It is hoped that those of you receiving this memorandum will use the newly-revised forms beginning immediately to assist the Commission in providing its services as efficiently and effectively as possible. Thank you for your anticipated cooperation.