Fill and Sign the Settlementadvance Recap Sheet Montana Form

Instructions: Note: SECTIONS 1,5,6 & 7 ARE MANDATORY FOR ALL SETTLEMENTS 1. Claimant Name – please spell correctly D/A or OD: List date of injury or if an occupational disease, date used by insurer as onset date. Claim #: Use Insurer’s claim number SSN#: List claimant’s social security number. Date of Birth: Include correct year. 2. This section is to document financial sustainment per Administrative Rule 24.29.1201 MCA (for Dates of Accident from 4/15/85 to 6/30/87 see ARM 1201-1204) Pre and post lump sum income should reflect the monthly income from all sources. Pre and post lump sum Expenses should reflect the claimant’s monthly expenses. 3. MMI: Rating – provide the whole man rating percentage. Paid: indicate if rating has been paid to the claimant. Rehabilitation Panel Option: Provide option found by panel, or mark N/A if panel was not held. Wage Supplement Rate: Reflect rate on which settlement is based. Social security Offset: Provide the offset being applied to the Total Rate on Permanent Total Disability cases. 4. MMI: Provide the date the claimant reaches MMI, or is provided an impairment rating or for Occupational Diseases is released to return to work. 5. Settlement Information: This section is to be filled out for all dates of injury. Provide the date the claimant reaches MMI, or is provided an impairment rating or for Occupational Diseases is released to return to work Settlement/Lump sum advance Amount. Provide the dollar amount of the settlement or advance. Rationale/Calculations: Provide a brief explanation of the reason for settlement and the calculations used to obtain the settlement amount. 6. Claimants Signature: The claimant or his/her authorized representative can sign this. Insurer’s Signature: The representative of the insurer can sign this. 7. Attorney: If represented list claimant’s attorney’s name and the fees being charged on this settlement (do not include costs). 8. This section is to be completed by ERD staff. EMPLOYMENT RELATIONS DIVISION SETTLEMENT/ADVANCE RECAP SHEET Please complete the applicable sections PETITION TITLE:       1. CLAIMANT:       ERD Claim#:       D/A or OD:       (Include all Claims) CLAIM (S) #:       2. DATES OF INJURY PRE 7/1/87 *Pre Lump Sum: *Post Lump Sum: Income: $       Expenses: $       Differences: $       Income: $       Expenses: $       Differences: $       For dates of injury prior to April 15, 1985: See Instructions For dates of injury between April 15, 1985 and June 30, 1987: See Instructions 3. DATES OF INJURY POST 7/1/87 Impairment Rating:       % Paid: Yes No Wage Supplement Rate: $       Wage Supplement Calculation:       For Lump Sum Advances and Permanent Total Disability Settlement: See Instructions 4. DATES OF INJURY POST 7/1/91 703 Benefits: PPD Rate: $       Age:     % Education:     % Wage Loss:     % Restrictions:     % Impairment:     % Total Award: 0% % Claimant’s wage at the time of injury: $       Has the claimant been released to job of injury? Yes No Is the claimant currently working? ( If yes, current wage) Yes No Current Wage: $       For Permanent Total Disability Settlements/Advances: See Instructions 5. SETTLEMENT/LUMP SUM ADVANCE INFORMATION (ALL DATES OF INJURY) Impairment Rating or MMI date ( All settlements require MMI or date released to return to work ):       Settlement/Advance Amount: $       Settlement/Advance Rationale & Calculations ( include present value calculations if applicable ):       6. Claimant’s Signature: ___________________________ Insurer’s Signature: _____________________________ (or authorized representative) (or authorized representative) TO THE BEST OF MY KNOWLEDGE THE ABOVE INFORMATION IS TRUE AND CORRECT 7. Claimant’s Attorney:       Fee: $       (Do not include costs) 8. Reviewed by: _____________________________________ Date: ______________________________________ (ERD Examiner) Questions concerning this form should be addressed to: Employment Relations Division Claims Assistance Bureau Box 8011 Helena MT 59604-8011 Phone (406) 444-6539 Revised 1/97