You have reached the original website of the
Connecticut Workers' Compensation Commission.
Forms, publications, statutes, and most other
information is now located at our NEW site:
PORTAL.CT.GOV/WCC |
WCC MEMORANDUMS
ARE STILL LOCATED AT THIS SITE WHILE IN THE
PROCESS OF BEING MIGRATED TO OUR NEW SITE.
Click to read WCC MEMORANDUMS. |
WCC New and Revised Forms Memorandum - July 26, 2002
MEMORANDUM NO. 2002-04
| 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
You have reached the original website of the
Connecticut Workers' Compensation Commission.
Forms, publications, statutes, and most other
information is now located at our NEW site:
PORTAL.CT.GOV/WCC |
WCC MEMORANDUMS
ARE STILL LOCATED AT THIS SITE WHILE IN THE
PROCESS OF BEING MIGRATED TO OUR NEW SITE.
Click to read WCC MEMORANDUMS. |