Fill and Sign the Petition for Advance Montana Form

BEFORE THE DEPARTMENT OF LABOR & INDUSTRY Employment Relations Division P. O. Box 8011 Helena, Montana 59604-8011 ________________________________________ Claimant ________________________________________ Employer ________________________________________ Insurer PETITION FOR ADVANCE PERMANENT PARTIAL DISABILITY PERMANENT TOTAL DISABILITY Insurer’s Claim #: ___________________ ACN Claim #: ___________________ The claimant suffered an injury arising from a work-related accident or an occupational disease occurring on _________________________________________________. The insurer accepted liability for the claim. The claimant and insurer have agreed to a lump sum advance in the amount of __________________________________________________ ($ ____________________ ) . The purpose of this lump sum advance is for: ____________________________________________________ _________________________________________________________________________________________. The claimant understands the insurer may recoup this lump sum advance from any future benefits on a biweekly basis amortized at the current rate as established by the Department of Labor & Industry and/or recoup it from any award or settlement received in the future. Recoupment Provisions: _________________________________________________________________ ________________________________________________________________________________________ __________________________________ _____________________________________ Claimant’s Signature Witness Signature _______________________________________ _____________________________________ Address Date Signed ________________________________________________________________________________________ City State Zip The ________________________________________________ concurs and joins in the Petition for Advance. __ ___________________ ___________ ____________ Authorized Representative Date Order The Department of Labor & Industry hereby orders that the above settlement is approved. Dated the ___________ day of ________________________________________________________________. ___________________________________________ Signature of Authorized Department Representative Revised 7/05