Please TYPE or PRINT IN INK Voluntary Agreement EMPLOYEE Name D.O.B. (required) Address City/Town Zip Code Tel.# State This form is NOT a final settlement. Review, sign, and submit ALL 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. CONCURRENT EMPLOYMENT Rev. 5-7-2014 State of Connecticut Workers Compensation Commission WCC File # Insurer # VA (for WCC use only) Date filed in District q Check, if employee had MORE THAN ONE employer If concurrently employed, see reverse side for directions. INJURY EMPLOYER Name Address City/Town Zip Code Tel.# State Date of Injury (MM/DD/YY) Date Incapacity Began (MM/DD/YY) ............................................................................ City/Town of Injury State Zip Code ............................................................................ FICA withheld for the above-named employee? .............. Medicare ........................................................................... q q YES YES q q NO NO Cause of Injury Describe Specific Body Part(s) Injured and Nature of Injury: INSURER Name Address City/Town Zip Code Third Party Administrator Tel.# State Pol.# ............................................................................ q Occupational Disease Repetitive Trauma ............................................................................ Name of Authorized Physician q COMPUTATION OF AVERAGE WEEKLY WAGE The number of weeks worked* IF 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 $ 2 TEMPORARY PARTIAL Incapacity, Light Duty Job Differential, and/or Job Search, benefit paid per benefit rate table to a maximum of $ 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 for % loss, or loss of use, of body part(s)* *INDICATE Additional information (if required) (b) (c) Pursuant to C.G.S. § 31-308(b), the benefit computes to weeks beginning on (MM/DD/YY) , the date of Maximum Medical Improvement. at $ per week. per week. [C.G.S. § 31-308(a)]. divided into the Gross Wages earned $ equals the Average Weekly Wage $ *52 weeks is the maximum number allowed q master OR q non-master A Licensed Physicians 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) Authorized Signature of Respondent Name of Person Completing Form (please print) Date (MM/DD/YY) Date (MM/DD/YY) Tel. # (area code + number + extension) See reverse side for Calculations and Information on Concurrent Employment. American LegalNet, Inc. www.FormsWorkFlow.com WORKSHEET Calculating Concurrent Employment / Second Injury Fund Responsibility (C.G.S. § 31-310) Employee Name: 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: from (MM/DD/YY) to (MM/DD/YY) Total number of weeks = (A) Responsible Employer Address City/Town Zip Code Tel.# State Gross Wages earned from this employer during weeks of concurrent employment = $ (B) Concurrent Employer 1 Address City/Town Zip Code Tel.# State Gross Wages earned during weeks with Concurrent Employer 1 = $ Concurrent Employer 2 Address City/Town Zip Code Tel.# State Gross Wages earned during weeks with Concurrent Employer 2 = $ Add TOTAL Gross Wages earned from the Concurrent Employer(s) = $ (C) TOTAL GROSS WAGES Total number of weeks worked concurrently for all employers listed above (same as A) = Total Gross Wages earned from all employers during period of concurrent employment is (B) plus (C) = $ (D) (E) CALCULATION AND RESPONSIBILITY FOR PAYMENT OF BENEFITS Average 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 = $ 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 = $ Amount of compensation to be contributed by the Second Injury Fund (Form 44) is (F) minus (G) = $ (G) (H) (F) American LegalNet, Inc. www.FormsWorkFlow.com