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Fill and Sign the Petition for Commutation State of Delaware Division Form

Fill and Sign the Petition for Commutation State of Delaware Division Form

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PETITION FOR COMMUTATION TO THE INDUSTRIAL ACCIDENT BOARD OF THE STATE OF DELAWARE SITTING IN AND FOR COUNTY ) Claimant ) SS# Carrier File # ) vs. ) ) Carrier/Self-Insurer Name ) Employer ) ) Date of Injury Case File No. The undersigned prays that your Honorable Board sh all, after due notice of the time and place of hearing served on all parties in interest, hear and de termine the matter in accordance with the facts and the law, and state its conclusions of fact and rulings of law. Petition for Commutation of Bene fits, Pursuant to §2358: (Please check the appropriate blocks(s)) Total Disability, Pursuant to §2324 Partial Disability, Pursuant to §2325 Permanent Impairment, Pursuant to §2326 All Benefits, Except Medical Expenses 2 nd Injury Fund, Pursuant to §2327 All Benefits, Including Medical Expenses Medical Expenses Only Other Petition for Commutation of Benefits, Pursuant to §2358: The parties agree to the above settlement commu tation to be presented by stipulation to the board. The person who the parties agreed with is The parties contest the above commutation and request a pre-trial hearing. Dated this day of A.D. 20 . Name Address Document Control #: E60-07-12-12-11

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