KENTUCKY DEPARTMENT OF WORKERS' CLAIMS Frankfort, KY 40601 AGREEMENT AS TO COMPENSATION AND ORDER APPROVING SETTLEMENT Workers' Compensation Claim No. ____________________
IF THIS FORM IS NOT PROPERLY COMPLETED, IT WILL BE RETURNED. Every section should be filled in. If a section is not applicable, fill in the blank with N/A.
Claimant Social Security Number Address City, State, Zip Code Employer Address City, State, Zip Code Other party Address City, State, Zip Code Date of Birth Insurer/Self-Insured/Self-Insurance Group Insurer's Address City, State Zip Code
COAL WORKERS' PNEUMOCONIOSIS: INJURIOUS EXPOSURE Cause of disease: Length of exposure: __________________________ Date of last exposure: County in which exposure occurred: ________________ Brief description of history of exposure to coal dust: MEDICAL INFORMATION Medical expenses paid: $ Medical expenses unpaid or contested: $ Surgery performed: Yes No Hospitalization(s): Yes No Date of last medical payment: Nature of surgery: Length of hospital stay(s):
X-ray interpretations by B-readers: (Attach entire x-ray interpretation report) ILO Classification _______________ _______________ _______________ _______________ _______________ Date of Report ________________ ________________ ________________ ________________ ________________ Physician ______________________________ ______________________________ ______________________________ ______________________________ ______________________________
Has the Commissioner's Notice of Consensus been issued? _______Yes _______No If yes, specify the consensus finding and attach a copy of the notice: ___________________ ______________________________________________________________________________ Pulmonary function studies: (Attach entire medical report that provides ratings) FVC/FEV1 Date of Study Physician ______________________________ ______________________________ __________________ ________________ ______________________________ ______________________________________________________________________________ Diagnosis: __________________________________________________________________ If medical treatment is continuing, attach a copy of executed Form 113 indicating designated physician. WORK INFORMATION Type of work at last exposure: ____________________________________________________ Average weekly wage at time of last exposure: ________________________________________ Type of work performed at time of settlement: ________________________________________ BENEFIT AND SETTLEMENT INFORMATION Monetary terms of settlement: $ , to be paid as follows: ___ lump sum , ___ weekly for weeks, ____ by annuity, ___ other Total settlement amount: $ Percent of permanent disability: % Settlement computation: Does settlement amount include waiver or buyout of past or future medical expenses? Yes No. If yes, settlement amount for waiver or buyout: $ If settlement terms provide for lump sum representing weekly benefits greater than $100, does Yes No claimant have an adequate source of income during disability? Source of income: Amount: $ Does settlement include retraining incentive benefits? Yes No If yes, is claimant enrolled and actively and successfully participating in a bona fide training or education program approved by the Commissioner? Yes No Name of training or education program (Attach additional pages if necessary): OTHER INFORMATION If additional information is pertinent to settlement, explain, (Attach additional pages if necessary): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
CERTIFICATION OF PARTIES By signing this agreement, the parties and their representatives hereby certify that all sums paid pursuant to this agreement are in settlement of the plaintiff's coal workers' pneumoconiosis claim only and no sums have been included for any other claims or potential claims the plaintiff has against the defendant-employer. This the day of
Attorney or representative for claimant
Claimant (Signature) Attorney or representative for employer Address City, State, Zip
Attorney or representative for claimant (Name typed) Address City, State, Zip
ORDER APPROVING COAL WORKERS PNEUMOCONIOSIS SETTLEMENT AGREEMENT IT IS ORDERED that the above Agreement as to Compensation be and the same is hereby APPROVED. This the day of , 20 .
Administrative Law Judge
Pursuant to 803 KAR 25:009E, Section 27, the employer is required to file a written request for participation with the Kentucky Coal Workers' Pneumoconiosis Fund within 30 days of the Order Approving Settlement Agreement.