Free FORM - Connecticut


File Size: 262.8 kB
Pages: 2
File Format: PDF
State: Connecticut
Category: Workers Compensation
Author: WCC
Word Count: 763 Words, 5,041 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://wcc.state.ct.us/download/acrobat/va.pdf

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State of Connecticut Workers' Compensation Commission
Please TYPE or PRINT IN INK

Voluntary Agreement
EMPLOYEE
Name Soc. Sec.# (optional) D.O.B. (MM/DD/YY) Address City/Town Zip Code Tel.# State

VA
Date filed in District
(for WCC use only)

This form is NOT a final settlement.

Review and sign 4 copies. This does NOT close out your case. Your eligibility for Rehabilitation Services remains unaffected by this agreement. Certain individuals may be eligible to receive COLAs pursuant to C.G.S. 31-307a.
CONCURRENT EMPLOYMENT

Check, if employee had MORE THAN ONE employer
If concurrently employed, see reverse side for directions.

INJURY
Date of Injury (MM/DD/YY) Date Incapacity Began (MM/DD/YY) ............................................................................ City/Town of Injury State Zip Code

EMPLOYER
Name Address City/Town Zip Code FICA withheld for the above-named employee? Tel.# YES NO State

............................................................................ Cause of Injury Describe Specific Body Part(s) Injured and Nature of Injury:

INSURER
Name Address City/Town Zip Code Third Party Administrator Tel.# State Occupational Disease Repetitive Trauma ............................................................................ Name of Authorized Physician Pol.#

............................................................................

COMPUTATION OF AVERAGE WEEKLY WAGE
The number of weeks worked* IF THE BENEFIT IS FOR: 1 -- TOTAL Incapacity, the Basic Compensation Rate is based upon the appropriate benefit rate table [C.G.S. 31-307]. Employer to pay to employee $ 2 -- TEMPORARY PARTIAL Incapacity, Light Duty Job Differential, and/or Job Search, benefit paid per benefit rate table to a maximum of $ 3 -- PERMANENT PARTIAL Disability, the Specific Award is paid at the Basic Compensation Rate [C.G.S. 31-308(b)], according to the following: (a) Employer to pay employee for % loss, or loss of use, of body part(s)* *INDICATE (b) (c) Pursuant to C.G.S. 31-308(b), the benefit computes to weeks beginning on (MM/DD/YY) master OR at $ non-master , the date of Maximum Medical Improvement. per week. per week. [C.G.S. 31-308(a)]. divided into the Gross Wages earned $ equals the Average Weekly Wage $ *52 weeks is the maximum number allowed

A Licensed Physician's Report, as well as Form 1A ("Filing Status & Exemption"), MUST be attached or this form will NOT be processed.

AGREEMENT AND APPROVAL The Voluntary Agreement will NOT be processed without both signatures and the Form 1A, "Filing Status & Exemption".
The undersigned parties acknowledge and accept all of the facts stated above, subject to C.G.S. 31-315.

WORKERS' COMPENSATION COMMISSION APPROVAL
(for WCC use only)

Employee Signature (and parent/guardian, if minor)

Date (MM/DD/YY)

Authorized Signature of Respondent

Date (MM/DD/YY)

Name of Person Completing Form (please print)

Tel. # (area code + number + extension) See reverse side for Calculations and Information on Concurrent Employment.

Rev. 3-17-2006

WCC File # Insurer #

WORKSHEET
Calculating Concurrent Employment / Second Injury Fund Responsibility
(C.G.S. 31-310)

Employee Name:

If the injured employee was working for more than one employer on the date of the injury, the employer in whose employ he/she was injured is responsible for (1) all medical costs and either (2) the entire weekly compensation rate (if wages earned from this employer entitle the injured employee to the maximum compensation rate) or (3) a pro rata portion of the weekly compensation rate based on the calculations below. Only wages earned during the "weeks of concurrent employment" listed below (A) can be used in the calculations. Weeks of Concurrent Employment: from
(MM/DD/YY)

to
(MM/DD/YY)

Total number of weeks =

(A)

Responsible Employer Address City/Town Zip Code Tel.# State

Gross Wages earned from this employer during weeks of concurrent employment = $

(B)

Concurrent Employer 1 Address City/Town Zip Code Tel.# State

Gross Wages earned during weeks with Concurrent Employer 1 = $
Concurrent Employer 2 Address City/Town Zip Code Tel.# State

Gross Wages earned during weeks with Concurrent Employer 2 = $ Add TOTAL Gross Wages earned from the Concurrent Employer(s) = $ (C)

TOTAL GROSS WAGES Total number of weeks worked concurrently for all employers listed above (same as A) = Total Gross Wages earned from all employers during period of concurrent employment is (B) plus (C) = $ (D) (E)

CALCULATION AND RESPONSIBILITY FOR PAYMENT OF BENEFITS Average Weekly Wage for all employers is (E) divided by (D) = $ (See the Benefit Rate Table that coincides with the date of injury.) Total incapacity compensation rate for this AWW = $ Average Weekly Wage for responsible employer is (B) divided by (D) = $ (See the Benefit Rate Table that coincides with the date of injury.) Total incapacity compensation rate for this AWW = $ Amount of compensation to be contributed by the Second Injury Fund (Form 44) is (F) minus (G) = $ (G) (H) (F)