Free lump sum settlement - Maine

LUMP SUM SETTLEMENT
STATE OF MAINE WORKERS' COMPENSATION BOARD STATION 27, AUGUSTA, MAINE 04333-0027
1. INSURER FILE NUMBER: 2. EMPLOYER NAME: 6. SOCIAL SECURITY NUMBER 8. EMPLOYEE LAST NAME: 7. WCB FILE NUMBER: 9. FIRST NAME: 10. M.I.:

3. EMPLOYER MAILING ADDRESS AND PHONE NUMBER:

11. ADDRESS-NUMBER AND STREET:

4. INSURER NAME:

12. CITY:

13. STATE:

14. ZIP:

15. HOME PHONE:

5. INSURER MAILING ADDRESS:

16. DATE OF INJURY:

17. DESCRIPTION OF INJURY:

18. STRUCTURED SETTLEMENT (ATTACH DOCUMENTATION) 19. PERMANENT IMPAIRMENT RATING

TYPE OF SETTLEMENT: LUMP SUM SETTLEMENT TOTAL VALUE OF SETTLEMENT $ % AMOUNT PAID $

20. COMMENTS:
21. PREPARER NAME AND TITLE (TYPE OR PRINT): 22. TELEPHONE NUMBER: 23. DATE:

RELEASE
24.

EMPLOYEE/DEPENDENT:
I AM THE PERSON ENTITLED TO WORKERS' COMPENSATION BENEFITS ON ACCOUNT OF THIS INJURY OR DEATH. I HAVE READ THIS WORKSHEET AND ALL ATTACHMENTS. WHEN I RECEIVE THE AMOUNT SHOWN ABOVE AND THIS SETTLEMENT IS APPROVED BY THE HEARING OFFICER, I RELEASE THE EMPLOYER AND INSURER NAMED ABOVE FROM ALL FURTHER LIABILITY FOR THIS INJURY. I CONCENT TO THE SETTLEMENT.

EMPLOYEE/DEPENDENT SIGNATURE

ATTORNEY SIGNATURE

DATE

EMPLOYER/INSURER:
THE EMPLOYER CONSENTS TO THE SETTLEMENT: THE INSURER CONSENTS TO THE SETTLEMENT: YES YES NO NO SIGNATURE SIGNATURE DATE DATE

DECISION
25. THE REQUESTED SETTLEMENT (IS/IS NOT) APPROVED. THE EMPLOYER/INSURER IS ORDERED TO PAY
CIRCLE ONE

THE EMPLOYEE/DEPENDENT THE SUM OF $ ______________________________ IN A LUMP SUM SETTLEMENT ACCORDING TO THE WORKERS' COMPENSATION ACT. THE EMPLOYER/INSURER IS ORDERED TO PAY ALL OUTSTANDING COMPENSATION OBLIGATIONS INCURRED PRIOR TO THIS SETTLEMENT BY THE EMPLOYEE/DEPENDENT. THEEMPLOYER/INSURER IS ORDERED TO PAY THE ATTORNEY OF THE EMPLOYEE/DEPENDENT A FEE OF $ ______________________________________ ALL PENDING PETITIONS BASED ON THIS CLAIM ARE HEREBY DISMISSED.

HEARING OFFICER SIGNATURE
THIS DOCUMENT MAY BE PRODUCED IN ALTERNATIVE FORMATS SUCH AS BRAILLE, LARGE PRINT AND AUDIOTAPE. WCB 10 (3/98)

DATE