Free FORM - Connecticut

State of Connecticut Workers' Compensation Commission

STIPULATION TO DATE AND WHAT IT MEANS

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. ______

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____________________________ 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