Free FORM - Connecticut

WCC File #: _______________________________ Workers' Compensation Commission: STIPULATION AND WHAT IT MEANS
A stipulation is a full and final settlement of your case. Once it is approved by the Commissioner, your case is closed. You cannot recover any further benefits from this employer for this injury. Acceptance of this settlement means that you are waiving your rights to a formal hearing, which is a trial, regarding any issues that your employer or the insurance company may be disputing. By accepting this stipulation, you give up your rights to any future medical, disability, or loss of income benefits to which you might be entitled. Those benefits include: 1. Payment of all future medical bills you might incur for services related to this injury; 2. Future periods of temporary total and/or temporary partial benefits to which you may be entitled as a consequence of this injury; 3. A specific indemnity award for your permanent partial disability, if any; 4. Additional specific indemnity benefits should your permanent partial disability worsen over time as a result of the natural degeneration of your condition; 5. Additional lost earnings benefits under Section 31-308a if at the end of a specific indemnity award you are unable to earn equivalent wages; 6. Group health insurance under Section 31-284b. (Applies to state and municipal employees only.) 7. Any claim under Section 31-290a. (For example, if you were laid off or terminated due to this workers' compensation claim.) However, you will continue to be eligible for Vocational Rehabilitation assuming you meet all eligibility requirements. If you have any questions regarding the Stipulation or its effect on your entitlement to future benefits, please ask the Commissioner. If not, please read and initial the following: A) I understand the issues discussed above. ______________ B) I want to settle my case by way of the Stipulation. ______________ Please indicate your acceptance of these conditions by signing your name below. ______________________________ Print Claimant's Name ______________________________ Signature Date ______________________________ Commissioner Date
For Out of State Claimants:

________________________________ Print Name of Attorney/Witness ________________________________ Signature Date

All Stipulation documents must be notarized.

________________________________ Notary Date

4/03