Free Exhibit - District Court of Connecticut - Connecticut

Case 3:03-cv-00674-WWE Document 35-10 Filed O2/11/2005 Page1 of 2
Exhibit 23

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Case 3:03-cv—00674-WWE Document 35-10 Filed 02/11/2005. Pagle 2 or 2 0 mf
43 I Wet, FILE #
` COMPENSATION DISTRICT 4**
STATE OF CONNECTICUT p
1 A WORKERS COMPENSATION COMMISSION ·
NOTICE TO COMPENSATION COMMISSIONER AND EMPLOYEE
OF INTENTION TO CONTEST LIABILITY TO PAY COMPENSATION
` . V . I (Type or Print in Ink) I
Employee Infomation I Injury Information
I EMPLOYEE: Ronald Brenton K . DATE OF INJURY: l l/02/98 (alleged) I
SOC. SEC. # 049-30-4184 I TOWN OF INJURY: Stratford
ADDRESS 95 Norman Circle A - PART OF BODY: heart `
Stratford ‘ CT 06497 NATURE OF INJURY: irregular heart beat
TOWN STATE ZIP
I CAUSE OF INJURY: unknown
TEL‘# I OCCUPATIONAL ILLNESS OR REPETITIVE TRAUMA? l
p . Employer Infomation D Insurance Carrier Infomation
» CLAIM #: 138-9807935
EMPLOYER: Town of Stratford I
V . _ NAME OF INS. CO: Self-Insured c/0 CIRMA g ,
ADDRESS: 2725 Mem Street ADDRESS¤
New Haven I V CT 06535
saetrem . cr 06525 _ TOWN STATE ZIP .
TOWN STATE ZIP V
» CONTACT PERSON: Madelene Tassmer
TEL.# {203 [ 385-4008
‘ , TEL NO: g203) 946-3700
_ You are hereby notified that the undersigned employer will contest liability to compensation on the
employee named below on the following grounds, to wit: I
Respondents deny claimed heart condition as arising out of or during the course and scope of employment I
with the Town of Stratford on ll/2/98 or at any other time. The alleged to condition is personal in nature
and of unknown etiology. No medical documentation to substantiate exclusivity of alleged condition
to employment. Both medical bills and treatment are deferred to appropriate group insurance carrier.
_ Explanation: In accordance with the terms of the law, three copies of this notice are to be
made. One is to be iiled with the Commissioner, a second is to be served on the Employee,
and a third is to be served on the Provider. The copies shall be served either by personal p
presentation or by registered or certified mail. p
Rev. 5/4/98 I