Workers' Compensation Commission: Stipulation And What It Means
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1WCC 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
Print Name of Attorney/Witness
______________________________
________________________________
Signature
Date
Signature
Date
______________________________
Commissioner
Date
For Out of State Claimants:
________________________________
All Stipulation documents must be notarized.
Notary
Date
4/03
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