Alaska Department of Labor Alaska Workers Compensation Board P.O. Box 25512, Juneau, Alaska 99802-5512
COMPROMISE & RELEASE AGREEMENT SUMMARY
2. Insurer Claim Number
AWCB Case Number
INSTRUCTIONS: Complete and attach to the front of a compromise and release agreement submitted to the Alaska Workers Compensation Board. This form may not be used in place of or as a compromise and release agreement.
1. Employees Name (Last, First, Middle Initial) 4. Address City 7. Employee Attorney 9. Employer/Insurer Attorney 11. Other Party or Attorney 13. Explain Relationship to Case 15. How Did Accident Happen? 16. Describe Injuries. State Zip Code Telephone 8. Employer 10. Insurer 12. Other Party or Attorney 14. Explain Relationship to Case 3. Injury Date 5. Social Security Number 6. Birthdate (Age)
17. Medical Reports: All medical reports in the parties possession are attached. 18. Permanent Impairment Ratings
o Yes
o No
a. _____________ % of ________________________________________; ______________ % of ____________________________________________; ______________% of _________________________________________________________ By Dr. _________________________________________________________, Employees Physician b. _____________ % of ________________________________________; ______________ % of ____________________________________________; ______________% of _________________________________________________________ By Dr. _________________________________________________________, Employers Physician 19. Occupation Before Injury 23. Has Employee Returned to Work? o YES, Date: __________________________________ o NO (Explain Why) 20. Avg. Weekly Wage 21. Occupation After Injury 22. Weekly Wage
$
$
24. If Employee Returned to Work, is he working now? o YES o NO (Explain Why) o REGULAR WORK, Date: o MODIFIED WORK, Date: 25. Was Employee Released for Work? o NOT RELEASED Limitations: 26. Is Vocational Rehabilitation Needed? o NO o YES o UNKNOWN 27. Is Employee in a Vocational Rehabilitation Program? o NO o YES (Describe)
28. Projected Vocational Rehabilitation Program Completion Date 29. Summarize Dispute. a. Employee:
b. Employer:
Form 07-6117 (Rev. 1/94)
CONTINUED ON BACK . . .
COMPROMISE & RELEASE AGREEMENT SUMMARY (Continued from Front)
30. Summarize Payments Made to Date or Attach a Compensation Report with a Total Payment History. a. Compensation (Complete a separate line for different rates, types or disability interruptions): TYPE FROM THROUGH WEEKS & DAYS $ $ $ $ $ $ b. Medical $ 31. Agreed Settlement a. Compensation (Complete a separate line for different rates, types or disability interruptions): TYPE FROM THROUGH WEEKS & DAYS $ $ $ $ b. Medical Benefits Released? o NO c. Attorneys Fees $ e. REMARKS o YES, Amount: $ Paid By: o Employer o Employee o NO TOTAL COMPENSATION $ d. Vocational Rehabilitation Benefits Released? o YES, Amount: $ WEEKLY RATE $ $ $ $ TOTAL AMOUNT c. Other (Explain) $ TOTAL COMPENSATION $ WEEKLY RATE $ $ $ $ $ $ TOTAL AMOUNT LUMP SUM
f. Total Agreed Settlement Amount $ 32. Submitted by (Name of Person and Company or Firm) 33. Date
FOR AWCB USE ONLY 34. COMMENTS
35. DISPOSITION o APPROVE 36. By
o DISAPPROVE
o REQUEST INFORMATION
o RECOMMENDED HEARING
37. Date