Free FORM - Connecticut

File Size: 13.0 kB
Pages: 1
Date: July 21, 2008
File Format: PDF
State: Connecticut
Category: Workers Compensation
Author: WCC
Word Count: 162 Words, 1,080 Characters
Page Size: Letter (8 1/2" x 11")

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State of Connecticut Workers' Compensation Commission


A Stipulation to Date is a compromise of contested benefit claims up to the date of approval. These may include temporary total, temporary partial or permanent partial disability claims and medical benefits. By signing this form you acknowledge that you are aware that you are entering into an agreement / stipulation that will prevent you from seeking a formal hearing in the future on any of the issues that were raised in the stipulation.

If you have any questions regarding the Stipulation, or its effects on your entitlement to future benefits, ask them before signing. If not, then please initial the following: a.) I understand the issue discussed above. b.) I wish to resolve these contested issues by signing the Stipulation to Date. ______


____________________________ Witness Date

_____________________________ Claimant Date

NOTE: Signing this Stipulation to Date does NOT prevent you from making a claim for future benefits. Your case remains open.

April 2005