FORMS PAGE
The Nicholas Law Firm Forms
Critical Accident Information Pamphlet
Print this two-sided document (folded like a brochure) and keep it in your glove compartment. If you are ever involved in a car accident, this guide contains most of the important information necessary to protect your rights in a personal injury claim.
Print this two-sided document (folded like a brochure) and keep it in your glove compartment. If you are ever involved in a car accident, this guide contains most of the important information necessary to protect your rights in a personal injury claim.
| nlf_accident_guide.pdf |
Workers' Compensation Forms
- Authorization for the Release of Medical Records - Per the Connecticut Workers' Compensation Commission, this form "may be used by any hospital or provider for the purpose of administering a Connecticut workers’ compensation claim for benefits." The Nicholas Law Firm will use this form to request your injury-related medical records.
- Form 1A - Per the Connecticut Workers' Compensation Commission, this form "identifies the claimant’s tax filing status last filed prior to the date of injury." The Nicholas Law Firm uses this form to determine what your compensation rate is.
- Form WCR-1, Rehabilitation Request - Per the Connecticut Workers' Compensation Commission, this form "should be completed by the injured employee, or another party referring the injured employee, to apply for workers’ rehabilitation benefits administered by the Workers’ Compensation Commission."
- Mileage Worksheet - Per the Connecticut Workers' Compensation Commission, this form "may be used by an employee to report mileage incurred due to workers’ compensation-related medical appointments." This form is submitted to the insurance company to reimburse you for your travel expenses to injury-related medical appointments.
- Record of Employment Contacts (Job Searches) - Per the Connecticut Workers' Compensation Commissioner, this form "may be used by an employee to report contacts with employers during a job search while the employee is out on workers’ compensation." Many times, when an injured worker is still not fully ready to return to work but retains some work capacity, job searches are required. When the Nicholas Law Firm's attorneys ask you to perform "job searches," this is the form they are referring to.
Social Security Disability Forms
Appointment Representative Form - SSA 1696
In order for the Nicholas Law Firm's attorney to represent you before the Social Security Administration, the agency requires submission of this form signed by you and your attorney.
In order for the Nicholas Law Firm's attorney to represent you before the Social Security Administration, the agency requires submission of this form signed by you and your attorney.
| ssa-1696.pdf |
Authorization to Disclose Information to the Social Security Administration - SSA 827
This document allows us to submit information directly to the Social Security Administration on your behalf.
This document allows us to submit information directly to the Social Security Administration on your behalf.
| ssa-827_-_authorization_to_disclose_information.pdf |
Request for Reconsideration - SSA 561
This document allows or SSDI lawyers to request a "Request for Reconsideration" with the Social Security Administration on your behalf. The Request for Reconsideration is the first "appeal" of your denied claim in most cases.
This document allows or SSDI lawyers to request a "Request for Reconsideration" with the Social Security Administration on your behalf. The Request for Reconsideration is the first "appeal" of your denied claim in most cases.
| ssa-561_-_request_for_reconsideration.pdf |
Request for Hearing by Administrative Law Judge - HA 501
This document allows our SSDI lawyers to request a hearing before an Administrative Law Judge with the Social Security Administration on your behalf. The Request for Hearing by Administrative Law Judge is the second "appeal" of your denied claim in most cases, and officially requests an in-person (or video) hearing before an Administrative Law Judge at the Office of Disability Adjudication and Review.
This document allows our SSDI lawyers to request a hearing before an Administrative Law Judge with the Social Security Administration on your behalf. The Request for Hearing by Administrative Law Judge is the second "appeal" of your denied claim in most cases, and officially requests an in-person (or video) hearing before an Administrative Law Judge at the Office of Disability Adjudication and Review.
| ha-501_-_request_for_hearing_w_alj.pdf |
Disability Report - Appeal - SSA 3441
This document is completed by SSDI claimant's whose claim has been denied. It allows the claimant to describe updates to their medical treatment, education, work history, and more.
This document is completed by SSDI claimant's whose claim has been denied. It allows the claimant to describe updates to their medical treatment, education, work history, and more.
| ssa-3441_-_disability_report_appeal.pdf |
Medical Release Forms
Hospitals
- Waterbury Hospital - Waterbury, Connecticut
- Charlotte Hungerford Hospital - Torrington, Connecticut
- St. Mary's Hospital - Waterbury, Connecticut
- Yale New Haven Hospital - New Haven, Connecticut
- University of Connecticut Health Center / John Dempsey Hospital / UConn Medical Group - Farmington, Connecticut
- Middlesex Hospital - Middletown, Connecticut
- Hartford Hospital - Hartford, Connecticut
- St. Francis Hospital - Hartford, Connecticut
- Litchfield Hills Orthopedic Associates - Torrington, Connecticut
