California 13. Amount injured person is earning, or is able to earn in some suitable employment or business after the accident: $. . . . . . per week; $...... per month. 14. Payment, allowance or benefit received from employer during period of disability: $...... account medical care and attendance; $...... per week for...... weeks' total disability; $. per week for.... .weeks' partial disability. ..... 15. Additional amount claimed as compensation: $......account medical care and attendance; $...... per week for..... weeks' total disability; $........per week for..... weeks' partial disability. 16. Date of service on the employer of notice of accident.... 17. If notice not served within thirty days, reason for omission to serve same. 18. If application is filed to adjust claim for death, state name, address and relationship of all dependents. If to adjust claim for medical attendance or funeral expenses, state name and address of all other such creditors and amount of claims, if known: Name..... Address... ; Name..... Address.. .; Name.. Address... Address.. Name IV (Here state any further facts that may be desired)... WHEREFORE YOUR PETITIONER PRAYS, That the above-named respondent.. be required to answer this petition, that a time and place be fixed for hearing hereof and due notice thereof given, and that upon such hearing, an order or award be made by your Honorable Commission granting such relief as the said applicant.. may be entitled to in the premises. Dated at. this.. ..day of.. (Signed). NOTE.-When application is completed and signed by the applicant, the original, together with one copy for each respondent, should be filed with or mailed to the Industrial Accident Commission. Either party may be represented in person, by attorney or other agent. To the above-named defendant. You are hereby notified that the application of... entitled as above to adjust a claim for compensation arising out of injuries sustained by the death of (a copy of which is attached hereto) has been filed in the office of the Industrial Accident Commission of the State of California, California. Street, In the event that you desire to make any answer to the said application your attention is called to the following rules adopted by this Board, relative to the same, to wit: "RULE VII-ANSWER. When any defendant desires to disclaim any interest in the subject-matter of the claim in controversy, or considers that the application is in any respect inaccurate or incomplete or desires to bring any fact, paper or document to the attention of the Board as a defense to the claim or otherwise, he must, within ten days after the service of the application, file with or mail to the Board his answer, setting forth the particulars in which the application is inaccurate or incomplete and the facts upon which he intends to rely. A copy thereof must likewise be served upon each party to the proceedings. Any material allega California tion contained in the application and not controverted in the answer will be deemed to be admitted." "RULE VIII-SERVICE. Where a pleading or document is served by mail, it shall, unless the contrary be proved, be deemed to have been served, at the time when the letter containing the same would have been delivered in the ordinary course of post. Proof of such mailing shall be prima facie proof of service." And you are further hereby notified that unless you appear and answer within ten days after the service on you of this notice, said Applicant.. will apply to the Board for the relief prayed for. Witness: INDUSTRIAL ACCIDENT COMMISSION Of the State of California, this..... .day of...... 191.. Member Secretary. STATE OF CALIFORNIA, being duly sworn, deposes and says: That he is, and was at the times of the service of the papers herein referred to, a citizen of the United States, over the age of eighteen years, and not a party to the within-entitled proceeding; that he personally served the within notice on the hereinafter-named defendants, by delivering to and leaving with each of said defendants personally, in the City and County of........, State of California, at the times set opposite their respective names, a copy of said notice attached to a copy of the complaint referred to in said notice. Names of Defendants Served: Date of Service: The People of the State of California Send Greeting to: Defendant You are hereby notified that the application of. entitled as above, to adjust a claim for compensation arising out of injuries sustained by the death of has been set for hearing and will be heard at. on the.... .day of....... 191., at........o'clock ...M., and you are hereby further notified that in default of your attendance at the time and place above mentioned, the Industrial Accident Commission of the State of California will proceed to hear and dispose of the said application in the manner provided by law. Witness: INDUSTRIAL ACCIDENT COMMISSION Dated at San Francisco, California, this day of. . . . . . . ., 191.. Member-Secretary. Connecticut CONNECTICUT The administration of the Act is vested in five Commissioners, one for each Congressional district. All communications relating to the administration of the Act should be addressed to the Compensation Commissioner of the district in which the controversy arises. The names and addresses of the Commissioners are as follows: FIRST DISTRICT (Hartford County). Commissioner, George B. Chandler, 209 Pearl Street, Hartford. SECOND DISTRICT (Tolland, Windham, New London and Middlesex Counties). Commissioner, Dr. James J. Donohue, 748 Main Street, Willimantic. THIRD DISTRICT (All of New Haven County, except the towns of Southbury, Middlebury, Waterbury, Wolcott, Oxford, Naugatuck, Prospect, Beacon Falls, Seymour, Ansonia and Derby). Commissioner, Talcott H. Russell, 42 Church Street, New Haven. FOURTH DISTRICT (Fairfield County). Commissioner, Edward T. Buckingham, 1024 Main Street, Bridgeport. FIFTH DISTRICT (All of Litchfield County and the following towns in New Haven County; Southbury, Middlebury, Waterbury, Wolcott, Oxford, Naugatuck, Prospect, Beacon Falls, Ansonia, Seymour and Derby). Commissioner, Frederic M. Williams, Lilley Building, Waterbury. Forms for the administration of the Act are distributed to the town clerks of the various towns throughout the State from whom any party in interest may secure the same. Form No. 11 is an agreement in regard to compensation between the employer and the employé. Form No. 12 is an agreement in case injuries result in death. Form No. 13 is a notice from the employer of a failure to agree in regard to compensation which must be served on the Commissioner. Form No. 14 is a notice from the employé of failure to agree in regard to compensation which must be served on the commissioner. The proceedings before a commissioner on a disputed claim are as specified in Part B, §§ 17 to 27 inclusive. |