Stipulation Questionnaire

WCC File # ________________ State of Connecticut Workers' Compensation Commission STIPULATION QUESTIONNAIRE Claimant ________________________ v. Respondent _________________________ The following information will be necessary for approval of the stipulation. Please include information regarding all relevant injuries. 1. Is this an accepted claim? 2. Was a Voluntary Agreement form approved? 3. What is the nature of the injury? 4. What is the claimant's base compensation rate? 5. Has the treating physician concluded treatment? Attach last report. 6. Has the claimant been rated for permanent partial disability? By whom? 7. What is the rating? 8. Has the permanent partial disability been paid? Partially or in full? 9. Have all medical bills been paid to date? 10. Are there any outstanding liens (e.g. Support Enforcement Services, Medical, AFDC/General Assistance, Attorney's Fees, etc.)? 11. Has the claimant applied for, or is she/he receiving Social Security Disability or Social Security Supplemental Income? 12. Is there a Medicare Set-Aside? If so, is it self-administered or company administered? 13. Please explain the basis for the amount arrived at in the Stipulation. 14. Attorney's fee ____________ 15. For the purpose of Rehabilitation Services: Is the claimant working?_______If yes: Employer__________________________________________ Job Title_________________________________F.T./P.T._______Salary (optional)_______________ _____________________________________ Commissioner District ____ ____________________________________ Signature of person completing questionnaire (Employer, Insurer, Attorney, or Other) Please print name and company below: ____________________________________ ____________________________________ 1/09 American LegalNet, Inc. www.FormsWorkflow.com