Free FORM - Connecticut

STIPULATION APPROVAL PROCEDURE Before you request a hearing with the Workers' Compensation District Office, be aware of the following. 1. Have knowledge of the following information, that is required by WCC to locate or establish claim file: Claimant's name Body Part Employer Town of Injury Date of Injury 2. The following information is necessary to schedule a Stipulation hearing: The Stipulation document The 15-question Stipulation Questionnaire The Stipulation And What It Means form In cases where liens exist, information regarding resolution of lien, either prior to approval of Stipulation, or upon the approval of the Stipulation Current medical report indicating the claimant's current disability status If the respondent does not plan to attend the hearing, they must supply a waiver of their right to attend the hearing, in writing, via telephone, or in the body of the Stipulation document (helps determine amount of time needed for notice of hearing) FAX or mail a copy of the Stipulation along with the above attachments to the district office when you are ready to request a Stipulation approval hearing. Be prepared to discuss and justify the following at the Stipulation hearing: The ability to show or state whether or not there are any outstanding medical bills and, if so, the amounts and who is responsible for paying them: the respondent or the claimant Claimant's attorney's fee and any expenses incurred If the Stipulation is complex (such as a large structured settlement) please check with the Commissioner prior to requesting the Stipulation appointment as to any documents the Commissioner might require If the claimant does not understand English well, please bring a translator with you. Pro Se (If you represent yourself): 1. The insurance carrier representative must fill out the Stipulation Questionnaire. 2. Check with the WCC district office to inquire whether the insurance carrier representative is required to appear at the hearing. 3. Proceeding will be on the record. At the hearing: 1. The claimant and claimant's attorney (if any) must attend the hearing. 2. A Stipulation hearing duration is usually no longer than 15 minutes. 3. The Commissioner will verify the claimant understands the Stipulation and insure the claimant has signed a Stipulation and What it Means form. 4. If the Commissioner approves the Stipulation, a copy will be provided to the claimant and a copy will be sent to the respondents that day. 5. If the Commissioner does not approve the Stipulation, she/he will explain to the parties why and direct what action is to be taken. Exceptions or Out-of-State: If the claimant is unable to appear for a Stipulation appointment, i.e., claimant lives out of state or is physically unable to appear, the following should be presented at the hearing by the claimant's attorney: 1. The Stipulation document, SIGNED by all parties and claimant's signature to be notarized. 2. A letter explaining why the claimant is unable to appear including claimant telephone number where claimant can be reached on the day of the hearing. 3. An affidavit of the claimant signed and notarized. The affidavit should include: Claimant's current city and state. Attorney fees, if applicable. How the parties arrived at the settlement. Verification that claimant understands the settlement, has no unanswered questions or doubts. 4. An affidavit of the claimant's counsel, signed and notarized, to include: Verification the Stipulation was explained. Indication that all health providers and medical bills have been paid to date. 5. A Stipulation and What It Means form signed and notarized. 6. If the Commissioner does not approve the Stipulation, the parties will be advised as to what actions need to be taken. 1/09