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Stipulation Questionnaire

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________________

WCC File #

State of Connecticut

Workers’ Compensation Commission

STIPULATION QUESTIONNAIRE

Claimant

________________________ v.

Respondent _________________________

The following information will be necessary for approval of the stipulation.

Please include information regarding all relevant injuries.

1. Is this an accepted claim?

2. Was a Voluntary Agreement form approved?

3. What is the nature of the injury?

4. What is the claimant’s base compensation rate?

5. Has the treating physician concluded treatment? Attach last report.

6. Has the claimant been rated for permanent partial disability? By whom?

7. What is the rating?

8. Has the permanent partial disability been paid? Partially or in full?

9. Have all medical bills been paid to date?

10. Are there any outstanding liens (e.g. Support Enforcement Services, Medical, AFDC/General

Assistance, Attorney’s Fees, etc.)?

11. Has the claimant applied for, or is she/he receiving Social Security Disability or Social Security

Supplemental Income?

12. Is there a Medicare Set-Aside? If so, is it self-administered or company administered?

13. Please explain the basis for the amount arrived at in the Stipulation.

14. Attorney’s fee ____________

15. For the purpose of Rehabilitation Services:

Is the claimant working?_______If yes: Employer__________________________________________

Job Title_________________________________F.T./P.T._______Salary (optional)_______________

_____________________________________

____________________________________

Commissioner

Signature of person completing questionnaire

District ____

(Employer, Insurer, Attorney, or Other)

Please print name and company below:

____________________________________

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Stipulation Questionnaire

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