State of Connecticut Workers' Compensation Commission

MEMORANDUM NO. 1999-13

VOLUNTARY AGREEMENT FORM REVISED 7/20/99

 

TO: Commissioners, District Administrators, Self-Insureds, Insurance Carriers, Attorneys, Unions, Medical Practitioners, and Advisory Board Members
FROM: Jesse M. Frankl, Chairman
DATE: July 22, 1999
RE: VOLUNTARY AGREEMENT FORM REVISED 7/20/99

 

We are pleased to announce a revision of the Voluntary Agreement (Form WCC-1).

The enclosed BLUE form, effective July 20, 1999, reflects a change in the method of calculating concurrent employment for all injuries occurring on or after July 1, 1995.

PLEASE NOTE THAT THIS FORM WILL BE ACCEPTED ON BLUE STOCK ONLY.

 

With this revision, the Workers’ Compensation Commission will now be accepting the following voluntary agreement forms:
 

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

This form is available from our website or any district office.