Fill and Sign the Agreement as to Compensation Kentucky Kentucky Form

FO R M 1 1 0 K E N T UCKY D E P ARTMENT OF W ORKER S ’ C L A I MS I N J UR Y 657 Ch a mbe r l i n Av e nu e , F r a nkf o r t , K e ntu ck y 40601 October 2016 Edition A G R EE M E N T A S TO C O MP E N S A T I ON W ork e rs’ Compens a t i on C laim No. IF T H IS FORM IS N O T P RO P ER L Y CO M P LETED , T H E S ETTLE ME N T WILL N O T B E A P P ROVED . E v e r y s e ct i o n s h o uld be c o m p le t ed. I f a s e ct i o n is n o t a p p lic a ble, f ill in t he bla n k w ith N/A. P lai n tif f / E m pl o y ee Insurer/Sel f-Insured/Se lf-Insurance G ro u p S o cial Sec u r i t y N u m b e r /G r e e n C a r d Insurer’s Mailing Address Date o f B irth City, State, Postal Code M a iling A ddr ess C i t y , State, P o s tal C od e De f e n d a n t/ E m p l o y er Additional Defendant Name Additional Defendant Mailing Address Additional Defendant City, State, Postal Code M a iling A ddr ess C i t y , State, P o s tal C od e Additional Other Defendant Name Additional Other Defendant Mailing Address Date of Injury: Where did injury occur: City/State/Postal Code: INJ U RY Additional Other Defendant City, State, Postal Code Brief description of occurrence resulting in injury: Causes of Injury: Body parts aff cted: Nature of Injury: M EDI C AL I N F OR M A TION I m p ai r m e n t % Date Given % % % % % Medical expenses paid: $ Medical expenses unpaid or contested: $ Date of last medical paym ent: Surgery performed: Yes No Nature of Surgery: I m p ai r m e n t r ati n g s c o ns i d e r ed in s ettl e m e n t: ( A tta c h e n tire m e d ical r e por t t h at pro v i d es r ati n gs ) Physician Restrictions on activities: Attach most recent medical report setting forth physical restrictions. Diagnoses: If medical treatment is continuing, attach a copy of the executed Form 113 indicating a designated physician. WORK INFORMATION Does plaintiff/employee qualify for increased benefits under KRS 342.730 (1)(c)1 or 2? Yes No Explain: Yes No Has the plaintiff/employee filed for Social Security Disability or Supplemental Security Income benefits? Yes No If “No”, does the plaintiff/employee intend to file for Social Security Disability or Supplemental Security Income benefits? Type of work performed at time of injury: Average Weekly Wage at time of injury: $ Type of work performed after injury: Wages upon returning to work : $ Post-injury return-to-work date: Type of work performed at time of settlement: BENE F IT A N D S E T T LE M ENT IN F OR M A T ION A m o u n t a nd d u r at i o n o f t e m p o r a ry t o ta l di s a bi l ity p a id t o d at e: B e g i n n i n g Date E n d Date $ p er w e e k # o f w e e k s Total F o r e a ch l u m p s u m o r inc o m e bene f it ag r e ed t o , s h o w y o ur c a lcul at i o n bel o w : T y p e R es po n s i b le p a r ty Fr eq u e n c y o f p a ym e n ts Start Date W e e k l y p a ym e n t r ate I m p ai r m e n t Ra t i n g G r id Fact o r M u ltiplier P a ym e n t a m o un t N u m b er o f W e ek s ( f o r i n c o m e b e n e f i t s ) P r ese n t Val u e ( f o r l u m p s u ms ) T o tal Total of Lump Sum and Income Benefits: Are t he fo ll o w ing w a i v e r s incl u ded i n t he m o ne ta ry s e tt l e m e nt? A m ou n t f o r W ai v e r( s ) B e g i n n i n g Date P a ym e n t A m o u n t Fr eq u e n c y # o f P a ym e n t s T o tal Val u eW ai v er o r b u y o u t o f p ast m e d i c a l b e n e f i t s Yes No $ Waiver or buyout of future medical benefits Yes No $ ( if y es, atta c h m o s t c u rr e n t m e d ical r e por t o r o ff ice n o te fro m tre a t i n g ph ys ica l ) W ai v er o f v o c a ti o n al r e h a b ili t ati o n Yes No $ W ai v er o f r i g h t to r e op en Yes No $ Total of Waivers: Mo ne ta ry t e r m s o f s e tt l e m e nt: Total Settl ement I f s ettl e m e n t te r m s pro v i d e f o r a l u m p s u m r e pr ese n t i n g w e e k l y b e n e f its g r e a ter t h a n $100 , do es cla i m a n t h a v e an a d e q u a te s o u r ce o f i n c o m e d u r i n g d i s a b ili t y Yes No Source of income: Weekly amount: $ OTHER INFORMATION If additional information is pertinent to the settlement, please explain (additional information may be attached to this form if required): Other responsible parties against whom further proceedings are reserved: I f w a i v ing m e d ic a l bene f it s , p lease a c kn o w le d g e b y s i g n i n g b el o w : I un d e r s t a n d t h at m y h e a l t h i n su r a n ce m a y n o t co v er a n y m e d ical e x p e ns e s f o r m y i n j u r y a n d I m a y b e h eld r es pon s i b le fo r p a ym e n t o f m e d ical e x p e ns e s f o r m y i n j u r y . I f u r t h er s tate I un d e r s t a n d a n d h a v e b e e n a dv i s ed m e d ical b e n e f i t s p u r s u a n t to t h e Ke n t u c k y Wor k e r s ’ C o m p e n s ati o n A ct a r e p a y a b le f o r t h e c u r e a n d / o r r elief o f t h e e f f e c t s o f t h e i n j u r y w i t h o u t li m itati o n as to t i m e. I have not b e e n pr o m i s e d t h at a n y e n t it y w i ll a u t o m at i c a l l y p a y f o r m e d ical e x p e ns e s r elat e d to m y i n j u r y . I h a v e c o n f e rr ed w i t h m y tre a t i n g ph ys ici a n a b o u t m e d ical tre a t m e n t I m a y r e q u ire in t h e f u t u r e a n d I a m s ati s f ied t h at t h e a m o u n t b ei n g p aid f o r t h e w a i v er of f u t u r e m e d ical b e n e f its i s a d e q u ate to pro v i d e f o r t h at tre a t m e n t. P lai n tif f / E m p l o y ee S i g n a t u r e I f n o t r e present e d by a n A tto rne y , p lease a c kn o w le d g e b y s i g n i n g b el o w : I un d e r s t a n d t h at I h a v e a r i g h t to ob tain an A t t or n e y o f m y c h o ice to r e v i e w t h is A g r e e m e n t a n d b y s i gn i n g b el o w I a ckn o w le d g e t h at I h a v e w a i v ed t h at r i g h t. B y w a i v i n g t h at r i g h t, I un d e r s ta n d I w i l l b e h eld to t h e s a m e s ta n d a r d as an A tt or n e y a n d t h is A g r e e m e n t w i ll b e e n f or c e a b l e as if r e pr ese n ted b y A tt or n e y . P lai n tif f / E m p l o y ee S i g n at u r e A tt o r n e y f o r P lai n tif f / E m p l o y ee Si g n at u r e P lai n ti ff / E m p l o y ee Sig n a t ur e A tt o r n e y f o r P lai n tif f / E m p l o y ee N a m e t y p ed A tt o r n e y f o r De f e n d a n t/ E m p l o y er S i g n a t u r e M a iling A ddr ess M a ili n g A ddr ess C i t y , State, P o s tal C od e C i t y , State, P o s tal C od e T ele p h o n e N u m b er T ele p h o n e N u m b er Ot her P a r t icip at ing Pa r t ies: ORDER APPROVING SETTLEMENT AGREEMENT IT IS HEREBY ORDERED that the above Agreement as to Compensation is APPROVED. This the day of , . Administrative Law Judge