Fill and Sign the Kentucky Compensation Form

FO R M 11 0 K E N T UCKY D E P ARTMENT OF W OR K ER S ’ C L A I MS H e a r in g L o ss/ O cc u p a ti o n al D i s e as e / C W P 657 Ch a mbe r l i n Av e nu e , F r a n k fo r t , K e n t u c k 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 AN D O RD ER AP P R O V I N G SETTLE M E N T W ork e rs’ Compens a t i on C laim No. B e f o re IF T H IS FORM IS N O T P RO P ER L Y CO M P LETED , IT WI L L B E RET U RNED . 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 Street Address Date o f B irth 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 M a iling A ddr ess City, State, Postal Code Additional Defendant Name Additional Defendant Mailing Address Additional Defendant City, State, Postal Code Additional Other Defendant Name Additional Other Defendant Mailing Address C i t y , State, P o s tal C od e Additional Other Defendant City, State, Postal Code H E A R ING LO S S OR OCC U P AT I ONAL DI S EASE Occupational disease: Injury Type: Body parts affected: Cause of disease: Brief description of history of exposure: Length of exposure: Date of last exposure: Where did exposure occur: City/State/Postal Code: M EDI C AL I N F OR M A TION 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 ) I m p ai r m e n t Date Gi v e n P h y s ici a n % % % R estricti o n s o n a c t i v i t ies: Attach most recent medical report setting forth physical restrictions. Diagnoses: Pulmonary function studies considered in settlement: (Attach entire medical report that provides ratings) FVC FEV1 D ate o f St u d y P h y s ician Diagnosis: I L O C l a ss i f ica t i o n Date o f R e por t P h y s ici a n 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: Has t h e p la i n t i f f/ e m p l o y ee f i l e d f o r S o cial Sec u r i t y D i s a b ili t y o r S u pp l e m e n tal Se c u r i t y I n c o m e b e n e f it s ? Yes No I f ‘ N o ’ , do es t h e P lai n t i f f / E mp l o y ee i n t e n d to f ile f o r S o cial Sec u r i t y Di s a b ili t y o r S u pp l e m e n tal Se c u r i t y I n c o m e b e n e f it s ? Yes NoType of work performed at last exposure: Average Weekly Wage at last exposure: $ Type of work performed after return to work: Wages upon returning to work : $ 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 w e e k l y inc o m e b e ne f it p a y m e nt a g r e ed t o , s h o w yo 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: B e g i n n i n g Date ( f o r periodic p a ym e n ts only) P a ym e n t A m o u n t F r e q u e n c y # o f P a ym e n t s T o tal Val u eAre 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 o un t f o r W ai v e r( s ) W 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 $ W ai v er o r b u y o u t o f f u t u r e m e d ical b e n e f i t s 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 f r o m tre a t i n g ph ys ica l ) Waiver of vocational rehabilitation Yes No $ Waiver of right to reopen Yes No $ 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 nt 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: $ D o es sett l e m e n t i n c l u d e r et r ai n i n g i n c en ti v e b e n e f it s ? Yes No I f y es, i s cla i m a n t a c t i v e l y p a r tici p ati n g in i n s tr u cti o n o r trai n i n g pro g r a m ? Yes No N a m e o f i ns t r u cti o n o r trai n i n g pro g r a m ( atta c h e x p la n at o r y p a g es if n e c e s s a r y ) : O T H E R INFO RMATI ON 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 its , 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 , h e ar i n g l o s s , o r o c c u p ati o n al d i s e a s e and I m a y b e h eld r es po ns i b le f o r p a ym e n t o f m e d ical e x p e ns e s . 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 d v i s ed m e d ical b e n e f its p u r su a n t to t h e K e n t u c k y Wor k e r s ’ C o m p e ns a t i 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 , hearing l oss, o r o c c u p ati o n al d i s e a s e w i t h o u t l i m itati o n as to t i m e. I h a v e n o t b e e n pro m i s ed t h at a n y e n ti t y w ill a u t o m atic a l l y p ay f o r m e d ical e x p e ns es r elat e d to m y i n j u r y, h e ar i n g l o s s , o r o c c u p ati o n al d i s e a s e . 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 bo u t m e d ical tre a t m e n t I m a y r e q u i r e 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 ou n t b ei n g p aid f o r t h e w ai v er o f f u t u r e m e d i c al b e n e f i t s is 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 der 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 Sig n a t 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 i c ipa t 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