Voluntary Agreement Forms

 

link opens in new browser tab  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.

[NOTE: This form will be accepted on GREEN stock only:  ]

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

 


 

link opens in new browser tab  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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