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Please TYPE or PRINT IN INK Rev. 9-3-2010 State of Connecticut Workers Compensation Commission WCC File Insurer Date filed in District Physician s Permanent Impairment Evaluation The Form 42 should be mailed to ALL parties employee insurer attorneys. For WCC use only EMPLOYEE Name D. O. B. required INJURY Date of Injury Address City/Town City/Town of Injury State Zip Code Tel. EVALUATION IMPORTANT Use a separate Form 42 for EACH body part Connecticut Statutes do NOT recognize whole person ratings Section 31-308 b. Body Part Percentage of Permanent Loss or Loss of Use LIMB is. LEFT. RIGHT Maximum Medical Improvement Exam Date HAND ARM or THUMB is. MASTER. MINOR Does the patient have a work capacity. EYE is. If the patient DOES have a work capacity please list any physical restriction s Indicate complete and permanent loss of sight reduction of sight to one-tenth 1/10 or less of normal vision Which standards were utilized in your evaluation AMA Edition or Other Source CONNECTICUT-LICENSE....

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Related content

Form 42 - State of Connecticut Workers'...
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The Form 42 is to be completed by the examining licensed physician to report a claimant's permanent partial loss or loss of use of a body part, as well as the likely date of the claimant's maximum medical improvement.

How Long Does It Take to Reach a Settlement for Workers' Comp in Connecticut ? The entire settlement process—from filing your claim to having the money in your hands—can take around 12-18 months depending on the details of your case and whether or not you have legal representation.

Connecticut's Workers' Compensation Act, or Chapter 568 of the Connecticut General Statutes, is the body of law that specifically addresses issues of workplace injury and disease, benefits for which injured or ill employees may be eligible, insurance requirements to provide for benefits, how benefits are best to be ...

Connecticut requires businesses to carry workers' compensation insurance if they have one employee or more, regardless of whether they're contract, part-time, full-time, and regardless of the employee's average weekly wage.

The Form 6B is to be completed by an Officer of a Corporation or a Manager of a Limited Liability Company (LLC) who wishes to be excluded from workers' compensation insurance coverage. It is also used for such an officer or manager to revoke any previous election of exclusion from workers' compensation coverage.

Workers' Comp Exemptions in Connecticut LLC Members and Corporate Officers who include themselves under coverage for workers' compensation coverage must use a minimum of $1,450 per week ($75,400) or a maximum of $2,900 per week ($150,800).

What Is a Form 43 Denial in Connecticut? In Connecticut, when an employer or insurer believes that the employee's claim for compensation is partially or completely invalid, a Form 43 Denial is sent to that employee.

If you're a business owner, member of an LLC, corporate officer, partner in a partnership, sole proprietor, or independent contractor, you're not required to have workers' compensation coverage. Given the high cost of medical bills, you should consider purchasing this policy even when it's not required.

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Keywords relevant to Form 42 Ct

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  • Statutes
  • ama
  • physicians
  • reduction
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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232