VA Voluntary Agreement2002 State of Connecticut Workers' Compensation Commission22-7-Rev.WCC File # Insurer # Please TYPE or PRINT IN INKThis form is NOT a final settlement. Review and sign 4 copies. This does NOT close out your case. Your eligibility for Rehabilitation Services remains unaffected by this agreement. Certain individuals may be eligible to receive COLAs pursuant to C.G.S. § 31-307a.Date filed in DistrictConcurrent EmploymentEmployee Check, if employee had MORE THAN ONE employerIf concurrently employed, see reverse side for directions.(for WCC use only)Injury NameSoc. Sec.# (optional) D.O.B. (MM/DD/YY) AddressCity/TownStateDate of Injury (MM/DD/YY) Date Incapacity Began (MM/DD/YY) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Zip CodeTel.#EmployerNameCity/Town of InjuryAddressStateZip CodeCity/TownState. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cause of Injury Describe Specific Body Part(s) Injured and Nature of Injury:Zip CodeTel.# YES NOFICA withheld for the above-named employee?InsurerNamePol.#AddressCity/TownStateZip CodeTel.# Occupational Disease Repetitive Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Name of Authorized Physician. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Third Party Administrator Computation of Average Weekly WageThe number of weeks worked*divided into the Gross Wages earned $equals the Average Weekly Wage $*52 weeks is the maximum number allowedIF THE BENEFIT IS FOR:1 TOTAL Incapacity, the Basic Compensation Rate is based upon the appropriate benefit rate table [C.G.S. § 31-307]. Employer to pay to employee $per week.2 TEMPORARY PARTIAL Incapacity, Light Duty Job Differential, and/or Job Search, benefit paid per benefit rate table to a maximum of $[C.G.S. § 31-308(a)].3 PERMANENT PARTIAL Disability, the Specific Award is paid at the Basic Compensation Rate [C.G.S. § 31-308(b)], according to the following:(a)Employer to pay employee forper week.at $% loss, or loss of use, of body part(s)* master OR non-master*INDICATE, the date of Maximum Medical Improvement.(b)Pursuant to C.G.S. § 31-308(b), the benefit computes toweeks beginning on (MM/DD/YY)(c)A Licensed Physician's Report, as well as Form 1A ( Filing Status & Exemption ), MUST be attached or this form will NOT be processed.Agreement and Approval The Voluntary Agreement will NOT be processed without both signatures and the Form 1A, Filing Status & Exemption .The undersigned parties acknowledge and accept all of the facts stated above, subject to C.G.S. § 31-315.Workers' Compensation Commission Approval (for WCC use only)Employee Signature (and parent/guardian, if minor)Date (MM/DD/YY)Authorized Signature of RespondentDate (MM/DD/YY)Name of Person Completing Form (please print)Tel. # (area code + number + extension)See reverse side for Calculations and Information on Concurrent Employment.American LegalNet, Inc. www.USCourtForms.comWORKSHEETEmployee Name:Calculating Concurrent Employment / Second Injury Fund Responsibility(C.G.S. § 31-310)If the injured employee was working for more than one employer on the date of the injury, the employer in whose employ he/she was injured is responsible for (1) all medical costs and either (2) the entire weekly compensation rate (if wages earned from this employer entitle the injured employee to the maximum compensation rate) or (3) a pro rata portion of the weekly compensation rate based on the calculations below. Only wages earned during the weeks of concurrent employment listed below (A) can be used in the calculations. Weeks of Concurrent Employment: fromtoTotal number of weeks =(A)(MM/DD/YY)(MM/DD/YY)Responsible EmployerResponsible Employer AddressCity/TownStateZip CodeTel.#Gross Wages earned from this employer during weeks of concurrent employment = $(B)Concurrent EmployersConcurrent Employer 1 AddressCity/TownStateZip CodeTel.#Gross Wages earned during weeks with Concurrent Employer 1 = $Concurrent Employer 2 AddressCity/TownStateZip CodeTel.#Gross Wages earned during weeks with Concurrent Employer 2 = $Add TOTAL Gross Wages earned from the Concurrent Employer(s) = $(C)Total Gross WagesTotal number of weeks worked concurrently for all employers listed above (same as A) =(D)Total Gross Wages earned from all employers during period of concurrent employment is (B) plus (C) =$(E)Calculation and Responsibility for Payment of BenefitsAverage Weekly Wage for all employers is (E) divided by (D) =$ (See the Benefit Rate Table that coincides with the date of injury.)Total incapacity compensation rate for this AWW = $(F)Average Weekly Wage for responsible employer is (B) divided by (D) =$ (See the Benefit Rate Table that coincides with the date of injury.)Total incapacity compensation rate for this AWW = $(G)Amount of compensation to be contributed by the Second Injury Fund (Form 44) is (F) minus (G) =$(H)American LegalNet, Inc. www.USCourtForms.com
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