State of Connecticut Workers' Compensation Commission

MEMORANDUM NO. 1999-18

VOLUNTARY AGREEMENT FORMS

 

TO: Commissioners, District Administrators, Self-Insureds, Insurance Carriers, Attorneys, Unions, Medical Practitioners, and Advisory Board Members
FROM: John A. Mastropietro, Chairman
DATE: November 17, 1999
RE: VOLUNTARY AGREEMENT FORMS

 

The Workers' Compensation Commission will accept the following voluntary agreement forms:
 

  • GREEN for all injuries up to and including September 30, 1991
     
  • ORANGE for all injuries between October 1, 1991 and June 30, 1993*
     
  • GOLDENROD for all injuries between July 1, 1993 and June 30, 1995*
     
  • BLUE for all injuries occurring on or after July 1, 1995
     

* Please note that Memorandum No. 1999-13, dated July 22, 1999, incorrectly omitted the orange form.

[NOTE: This form is available from our website or any district office.]