Stipulation & Commutation Forms
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.
Stipulation and What It Means (Spanish)
PDF File: 1 page; Last revised September 21, 2022
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.
Indemnity Only Stipulation and What it Means
PDF File: 1 page; Last revised June 14, 2024
Indemnity Only Stipulation and What it Means
The Indemnity Only Stipulation and What it Means form must be signed by the claimant as a compromise of contested indemnity only benefit claims, and should be submitted with Stipulation paperwork prior to requesting a Stipulation Hearing
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
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).
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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