Fill and Sign the Lump Sum Settlement Form

Claimant's SS No. Employer's ID No. with a mailing address City or Town of State of Zip Code and Office Address arising from an injury which occurred on was employed by RSA 281-A:37, the parties jointly request approval of the settlement of $ Attorney Fees and Expenses totaling $ are hereby approved. THE STATE OF NEW HAMPSHIRE DEPARTMENT OF LABOR CONCORD NH 03301 LUMP SUM SETTLEMENT AGREEMENT (9-digit number assigned by proper Federal Agency) Insurance Carrier (Numbe r) (Name of Claimant or Dependent) (Number and Street) (Name of Employer or Insurance Company) (Name and Street) (City or Town) (Stat e)hereby acknowledge they have reached a mutual resolution of the matters in dispute between them , while the claimant was(Dat e) In accordance with the provisions of(Name of Employer) to be paid in alump sum. Social Security offset (if applicable). WITNES S: CLAIMAN T (Print Name) (Print Name) Dat e Dat e(Signatur e) (Signatur e) EMPLOYER OR INSURANCE COMPANY (Authorized By and Title) Dat e(Signatur e) The above request for the payment of Lump Sum Settlement is hereby approved. Commissioner or Commissioner's Representative Date Approved Initi al Form No. 15WCA(10-99) Page 1 of 6 Claimant Date of Birth Attained Age Current Address Employer Date of Injury Comp Rate $ AWW $ Carrier Claimant Attorney (if applicable) Carrier Attorney (if applicable) or (N) If yes, when? or (N) What is the status of appeal? LUMP SUM SETTLEMENT QUESTIONNAIRE RSA 281 -A:37 provides that lump sum settlement agreements for at work injuries may be permitted at the discretion of the Labor Commissioner or his designated representative when it is in the best interest of all concerned. Please provide the following information for the Department's consideration in reviewing the proposed lump-sum settlement. Have there been any hearings at the Department? (Y) Is there an appeal pending (Y) 1 . What is the claimant's current medical status? Please summarize briefly, then attach all current physician office notes, surgical reports, and any IME reports. (''Previously submitted'' is not an acceptable answer to this question.) 2. What specific date of injury is being settled? If there's more than one date of injury and it does not involve a recurrence, a separate lump sum settlement proposal must be completed and submitted. 3. What specific injury(ies) and/or condition(s) are being settled? Form No. 15WCA(10-99) Page 2 of 6 Full-Time or Part-Time or Light-Duty Full-Duty or (N) (N) (N) (N) 4. Has the treating physician released the claimant to work? (Y) Is the claimant working? (Y) 5. Briefly outline the claimant's education and work history. 6. Are there barriers to employment? (e.g., language, non-work related condition(s), etc.) (Y) If yes, please list: 7. Has a Permanent Impairment Award been previously approved by the Department?(Y ) If not, has there been a determination of permanent impairment that is included in this settlement? (Y) If yes, please attach the supporting medical report(s). 8. Are there any outstanding medical bills? (Y) a) List all bills that are to be paid as a condition of settlement. b) List all bills that remain in dispute and may become an issue for formal hearing at a later date. 9. What, if any, vocational rehabilitation services have been provided to the claimant? 10 . What are the claimant's vocational/employment prospects or plans? 11 . Has application been made or is the claimant receiving Social Security Disability benefits? (Y) If yes: a) When were they first applied for? b) When was the first payment received? Form No. 15WCA(10-99) Page 3 of 6 (N) (N) f) Trust or Guardianship g) Second Injury Fund/Concurrent Wages Application h) Attorney Lien(s) $ i) IRS Lien $ j) Mediation Expense $ Escrow Amount $ 1 2 Is a third-party action pending or anticipated? (Y) If yes: a) Is the claimant aware of the carrier's lien on future net third party proceeds? (Y) b) Is the claimant aware of the ''Holiday'' provisions in the event of future medical treatment? (Y) 13 . Has a third-party settlement been approved by either the Superior Court or Department of Labor? (Y) If yes, attach a copy of the approval order and workers' compensation carrier's confirmation of lien. 14 . Please check any additional issues that are applicable to this settlement and all documentation to substantiate such. attach a) NH Child Support Lien b) Social Security Offset c) Third Party Settlement d) Annuity Settlement and/or Payout Provisions e) Vocational Rehabilitation k) Other (Specify) 15 . In regards to this date of injury, will the claimant's representative or counsel continue to assist the claimant on follow-up medical bill hearings at the Department? 16 . Is the claimant under any pressure by anyone to lump-sum settle his/her claim at this time? (Y) If yes, please explain. 17 . Please provide the rationale and calculations that form the basis for this settlement proposal. If a vocational rehabilitation plan is included in these calculations, a copy of the approved rehabilitation plan must be attached: RATIONALE : (The reason why this case should be settled at this time). Form No. 15WCA(10-99) Page 4 of 6 CALCULATIONS: (List the actual figures for each item considered in the settlement. Add them and show the TOTAL SETTLEMENT). Note: If the carrier has waived all or part of its lien in a third party settlement, the amount waived must be included as part of the total settlement figure. For example, a payment of $10,000.00 to the claimant plus the waiver of a lien $14,500 = $24,500 total settlement. Claimant's Affidavit: I have read and understood all questions posed by this proposal and have no further questions as of the date of the lump sum settlement. Claimant's Signature Claimant's Attorney's Signature (if applicable) Dat e Dat e Carrier/Employer Representative Signature Dat e Form No. 15WCA(10-99) Page 5 of 6 CLAIMANT'S AFFIDAVIT This is to attest that I have been fully apprised of my rights under RSA 281-A the Workers' Compensation law. I understand that all my injured employee rights, including, but not limited to the following are forgone upon the Department of Labor signature on the Lump Sum Settlement. RSA 281-A:23- b Alternative Work Opportunities RSA 281- A:25 Vocational RehabilitationRSA 281-A:25- a Reinstatement of Employee Sustaining Compensable Injurie s RSA 281- A:28RSA 281-A:28- a RSA 281- A:31RSA 281-A:31 -a Compensation for Temporary Total Disability Compensation for Permanent Total Disability Compensation for Temporary Partial Disability Compensation for Permanent Partial RSA 281- A:32 Scheduled Permanent Impairment Award RSA 281- A:48 Review of Eligibility for Compensation, Extent of Disability However, pursuant to RSA 281-A:23, Medical, Hospital and Remedial Care, or RSA 281 - A:23-a, Managed Care, I have not forgone any future entitlement for medical care in settling workers' compensation claim. I additionally understand that the carrier, third party administrator, self-insured or employer has a right to controvert any future claims for Medical, Hospital and Remedial Care as it may relate to my claim(s) for any at-work injury if it should determine that such treatment is not reasonable or made necessary by such claims for any at- work injury. Dat e Witnes s Claiman t Form No. 15WCA(10-99) Page 6 of 6