In observance of Thanksgiving, WCC offices will be closed on Thursday, November 24, 2022.

Stipulation & Commutation Forms

 

link opens in new browser tab  Stipulation Approval Procedure

PDF File: 1 page; Last revised October 1, 2021
 

Stipulation Approval Procedure

The Stipulation Approval Procedure form is a purely informational document which outlines the procedures to take prior to requesting a Stipulation Hearing (including steps taken by a pro se or out-of-state claimant) and describes what occurs at a Stipulation Hearing.

 


 

link opens in new browser tab  Stipulation and What It Means

PDF File: 1 page; Last revised October 1, 2021
 

Stipulation And What It Means

The Stipulation And What It Means form is to be signed by the claimant, stating that he or she agrees to close out the case as a full and final settlement. This form should be submitted with Stipulation paperwork prior to requesting a Stipulation Hearing.

 


 

link opens in new browser tab  Stipulation TO DATE and What It Means

PDF File: 1 page; Last revised August 19, 2022
 

Stipulation TO DATE And What It Means

The Stipulation TO DATE And What It Means form must be signed by the claimant as a compromise of contested benefit claims up to the date of approval, and should be submitted with Stipulation paperwork prior to requesting a Stipulation Hearing

 


 

link opens in new browser tab  Stipulation Questionnaire

PDF File: 1 page; Last revised August 25, 2022
 

Stipulation Questionnaire

The Stipulation Questionnaire form contains questions that must be answered and submitted with Stipulation papers prior to requesting a Stipulation Hearing. Information regarding medical bills, liens, and other unpaid fees must be attached to the form (unless such documents have already been submitted).

 


 

link opens in new browser tab  Commutation and What It Means

PDF File: 1 page; Last revised August 19, 2022
 

Commutation And What It Means

The form Commutation And What It Means explains what a commutation is, and must be initialed and then signed by a claimant who wishes to receive a commutation of compensation benefits pursuant to Section 31-302 of the Workers' Compensation Act.

 


 

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