Voluntary Agreement Forms

  Voluntary Agreement

_{PDF File: 2 pages; Last revised May 7, 2014}
 

Voluntary Agreement

The Voluntary Agreement Form contains important information (including benefit calculations) regarding an injured employee’s claim, and should be completed and issued by the injured employee’s employer or its workers’ compensation insurance carrier in every case in which an injured or ill employee receives workers’ compensation payments.

Every Voluntary Agreement must be accompanied by the Filing Status And Exemption Form 1A, below.

  Form 1A

_{PDF File: 1 page; Last revised July 13, 2009}
 

Filing Status And Exemption Form

The Filing Status And Exemption Form 1A identifies the claimant's tax filing status last filed prior to the date of injury, and must be completed and submitted on all initial Voluntary Agreements for injuries occurring on or after October 1, 1991.

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