Fill and Sign the 6 Mb Comptrollers Report on the Study of the Risk Form

LAB 500 SETTLEMENT OF THIRD-PARTY CLAIM COMPUTATION 1. Full Amount of Settlement $ 2. Attorney Fees, Expenses, and Costs of Action (If any) $ 3. Attorney fees, Expenses, and Costs of Action as Percentage of Amount of Settlement (Divide Amount in Line 2 By Amount in Line 1) % EMPLOYER / CARRIER EMPLOYEE / CLAIMANT 4) Lien $ 7) Employee/Claimant’s Share (subtract line 4 from line 1) $ 5) Less: Pro Rata Share of Fees, 8) Less: Pro Rata Share of Fees, Expenses, and Costs of Action (Percent in Line 3 times Amount in Line 4) $ Expenses, and Costs of Action (Percent in Line 3 times Amount in Line 7) $ 6) Net Amount to Employer $ 9 ) Net Amount to Employee $ PROOF Line 5 – Pro Rata Share - Employer/Carrier Line 6 – Net Amount Owed - Employer/Carrier Line 8 – Pro Rata Share - Employee/Claimant $ $ $ Line 9 – Net Amount Due - Employee/Claimant $ Full Amount of Settlement (should equal line 1) TOTAL $ WC-3PR -1 (6/2015) Page1 of 2 LAB 500 Settlement of Claim For the sole consideration of (line 1) dollars ($ ), paid to me by or on behalf of (third-party exact name) receipt of which is acknowledged, I, , residing at do hereby release, acquit and forever discharge (third-party exact name) from any and all actions, causes of action, claims and demands, damages, costs, loss of services, expenses, and compensation, on account of or in any way growing out of any and all known and unknown personal injuries and property damage resulting or to result from the incident that arose on or about , 20___, by reason of and do hereby for myself, my heirs, executor, and administrator, successors and assigns, covenant with the said (third- party exact name) , to indemnify and save harmless from all claims and demands, costs, loss of services, expenses, and compensation on account of or in any way growing out of said incident or its result both to person and property. I acknowledge that a portion of such sole consideration shall be paid over as follows: pursuant to RSA 281-A:13, the amount of money in workers’ compensation, including the costs of disability benefits and medical care already paid or agreed to be awarded by the employer or insurance carrier named said amount being (line 4) dollars ($ ), less the employer’s or insurance carrier’s pro rata share of fees, expenses and costs of action, if any, being the amount (line 5) dollars ($ ), leaving a net amount of (line 6) dollars ($ ), which shall be paid to the employer or insurance carrier in satisfaction of its lien. Therefore, the net amount to be paid to me, after the worker’s compensation lien is satisfied, is (line 9) dollars ($ ). Signed this day of , 20 X Witness: Optional notarization: On the date , before me personally appeared known to me or proved to be the person described herein, and who voluntarily executed this document. Notary Public Approval of the Commissioner of Labor pursuant to RSA 281-A:13, III, granted this date: Commissioner of Labor WC-3PR -1 (6/2015) Page2 of 2