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COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS' COMPENSATION 1171 S. CAMERON STREET, ROOM 103 HARRISBURG, PA 17104-2501 (TOLL FREE) 800-482-2383

THIRD PARTY SETTLEMENT AGREEMENT

Social Security Number: Date of Injury:
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PA BWC Claim Number: Employer

Employee
First Name _______________________________ If Deceased - Dependent, Guardian First Name _______________________________ Street 1 Last Name _________________________________________ Last Name _________________________________________

Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County _________________________________ Telephone (______) _______-_______________ __________ __________-_______

___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ County __________ Telephone __________-_______

FEIN _________________________

___________________________________________ (______) _______-_______________

Insurer or Third Party Administrator (if self-insured)
Name

Employee's Attorney
Name ___________________________________________________________________________ Firm Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ __________ __________-_______ Telephone PA Attorney ID Number (______) _______-________________________ ________________________________

___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ Telephone (______) _______-_______________ County ______________________________ Claim Number ______________________________ __________ Bureau Code __________-_______

____________________________

FEIN ___________________________

Insurer's Attorney
Name

380 0306

___________________________________________________________________________ Firm Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ __________ __________-_______ Telephone PA Attorney ID Number (______) _______-________________________ ________________________________

LIBC-380 REV 3-06 (Page 1)

(OVER)

CALCULATION INSTRUCTIONS FOR COMPLETING BACK OF FORM
#1 -#2 -#3 -#4 to #8 -Enter the total amount of money received by the employee from the third party litigation. Enter the total amount of indemnity and medical benefits paid by the employer to the employee at the time of the third party recovery. Enter attorney fees and other expenses paid by the employee to obtain recovery in the third party action. Perform the calculations in the right column and enter the results into the center column.

In accordance with section 319 of the Pennsylvania Workers' Compensation Act, the parties herein have agreed to the following distribution of proceeds received from ________________________________________________________, third party:

Calculation
BASIC RECOVERY INFORMATION - Complete this section for all third party settlements. 1. Total Amount of Third Party Recovery 2. Accrued Workers' Compensation Lien a. Indemnity Benefits ______________ b. Medical Benefits ______________ 3. Expenses of Recovery 4. Balance of Recovery 1. 2. 3. 4.

________

= #1 (minus) #2

PRESENT DISTRIBUTION OF PROCEEDS - Complete this section to calculate the amount of proceeds the employer is to receive as of _____________________ (date through which Accrued Workers' Compensation Lien [#2] calculated). 5. Accrued Lien Expense Reimbursement Rate 6. Expenses Attributable to Accrued Lien 7. Net Lien (Amount employer to receive) 5. 6. 7. % __________ __________ __________ = #2 (divided by) #1 x 100 = #3 (times) #5 = #2 (minus) #6

FUTURE DISTRIBUTION OF PROCEEDS - Complete this section to calculate how much the employer must reimburse the employee for expenses used to acquire the third party recovery on future compensation liability. Note: This section is to be completed only if the total amount of the Third Party Recovery (#1) is greater than the amount of the Accrued Workers' Compensation Lien (#2). 8. Reimbursement Rate on future compensation liability. 8. % __________ = #3 (divided by) #1 x 100

9. The Employer/Insurer is responsible for ________% (#8) of any future weekly benefits and medical expenses to satisfy its obligation to reimburse its pro rata share of Employee's fees and expenses until the subrogation interest is exhausted; ______________(#4). Thereafter, the Employer/Insurer is responsible for 100% of any compensation liability. Further Matters Agreed Upon:

Employee's Signature Employee's Attorney Signature

Insurer's Signature Insurer's Attorney Signature

DATE OF THIS AGREEMENT: ____/____/_______ Any individual filing misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers' Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994.
LIBC-380 REV 3-06 (Page 2)
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Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program