State of Connecticut Workers' Compensation Commission

MEMORANDUM NO. 2002-04

NEW and REVISED FORMS

 

TO: Commissioners, District Administrators, Self-Insureds, Insurance Carriers, Attorneys, Unions, Legal Advisory Panel Members, and Advisory Board Members
FROM: John A. Mastropietro, Chairman
DATE: July 26, 2002
RE: NEW and REVISED FORMS

 

I am pleased to announce that the Commission has recently revised and redesigned four of its most-often used forms: (1) the "Voluntary Agreement" form, (2) the "43" form, (3) the "Employer's First Report of Occupational Injury or Illness" form, and (4) the "Notification of Appearance" form. Each of these forms now carries a revision date of 7-22-2002.

It is hoped that those of you receiving this memorandum will use the newly-revised forms beginning immediately to assist the Commission in providing its services as efficiently and effectively as possible. Thank you for your anticipated cooperation.

 

DIRECTIONS FOR USE OF THE NEW VOLUNTARY AGREEMENT FORM:
 

  • THE NEW VOLUNTARY AGREEMENT ("VA") FORM WILL BE ACCEPTED ON GREEN STOCK ONLY.
    (See the enclosed sample form.)
     
  • THE NEW "VA" FORM SHOULD BE USED FOR ALL TIME PERIODS.
    (The commission will no longer be using different forms for different dates of injury.)
     
  • THE FIRST PAGE OF THE NEW "VA" FORM MUST BE USED FOR ALL INJURIES.
     
  • THE SECOND PAGE (back) OF THE NEW "VA" FORM IS TO BE USED ONLY IN CASES IN WHICH THE INJURED EMPLOYEE WAS CONCURRENTLY EMPLOYED.
     

You can print and fill out the newly-revised forms online at:

https://portal.ct.gov/WCC/Home-Forms/Workers-Compensation-Forms

 

PLEASE NOTE:

  • Our newest online forms are distributed in Adobe Acrobat PDF format, version 5. If you are not using either the Acrobat Reader 5, Acrobat Approval 5, or the "full" Acrobat 5 software product, you will need to obtain the latest version of one of these software products to access and make use of our online forms.
     
  • Our forms are distributed electronically ONLY in Adobe Acrobat PDF format, version 5. We do NOT have versions available in word processing formats, such as WORD or WordPerfect.
     

For hard copies of the new forms, please contact:

Workers' Compensation Commission
Education Services
21 Oak Street, 4th Floor
Hartford, CT 06106-8011

Phone: (860) 493-1500
Fax: (860) 247-1361
E-Mail: wcc.chairmansoffice@po.state.ct.us