FORM 110-I INJURY Revised July, 2006
KENTUCKY DEPARTMENT OF WORKERS' CLAIMS Frankfort, KY 40601
AGREEMENT AS TO COMPENSATION
ORDER APPROVING SETTLEMENT
Workers' Compensation Claim No. ____________________
IF THIS FORM IS NOT PROPERLY COMPLETED, IT WILL BE RETURNED.
Every section should be completed. If a section is not applicable, fill in the blank with N/A.
__________________________________________ Claimant __________________________________________ Social Security Number Date of Birth ___________________________________________ Address ___________________________________________ City, State, Zip Code ___________________________________________ Employer ____________________________________________ Address ____________________________________________ City, State, Zip Code __________________________________________ Other participating parties __________________________________________ Address __________________________________________ City, State, Zip Code __________________________________________ Insurer/Self-Insured/Self-Insurance Group __________________________________________ Insurer's Address __________________________________________ City, State, Zip Code
INJURY Date: County in which injury occurred:____________________________ Brief description of occurrenc e resulting in injury:________________________________________ ________________________________________________________________________________ Nature of injury(ies) including body part(s) affected:______________________________________ MEDICAL INFORMATION Medical expenses paid: $ Date of last medical payment: ________________ Medical expenses unpaid or contested:$________________________________________________ Surgery performed (Circle one): Yes No Nature of surgery:__________________________ Impairment ratings: (Attach entire medical report that provides ratings)
Date Given Physician
% ________________________________ % ________________________________ % ________________________________ Restrictions on activities -- Attach most recent medical report setting forth physical restrictions. Diagnosis or diagnoses:_____________________________________________________________ If medical treatment is continuing, attach a copy of the executed Form 113 indicating a designated physician.
WORK INFORMATION Type of work performed at time of injury: ___________________________________________________ Average weekly wage at time of injury: $ Date of return to work after injury: _______________ Wages upon return to work: $ Type of work performed after injury:______________________ Type of work performed at time of settlement: ________________________________________________ BENEFIT AND SETTLEMENT INFORMATION
If consolidated Claims, indicate amount for each Claim separately:
Temporary total disability paid from _________ to _________ @ $_________*_______= $_________
(MM/DD/YR) (MM/DD/YR) Amount # wks Total
Monetary terms of settlement: ____________ paid in lump sum ____, or weekly for ________
# of weeks
Settlement computation: _______________________________________________________________
TTD * IMP. RATING *AMA FACTOR * RTW FACTOR * DISC. FACTOR OR # of WKS = TOTAL
Amount Waiver(s) Please circle: Waiver or buyout of past medical benefits Waiver or buyout of future medical benefits Waiver of vocational rehabilitation Waiver of right to reopen Yes Yes Yes Yes No No No No __________ __________ __________ __________
Does settlement include Medicare Set Aside? Yes No If yes, amount of Medicare Set Aside: ________
Periodic Payments: _________* __________*__________ = Amount Frequency Duration Other: Attach explanation
If settlement terms provide for lump sum representing weekly benefits greater than $100, does claimant have an adequate source of income during disability? Yes No Source of income: Amount: $___________________________
OTHER INFORMATION If additional information is pertinent to settlement, explain, (Attach additional pages if necessary): _____________________________________________________________________________________ _____________________________________________________________________________________ Other responsible parties against whom further proceedings are reserved: __________________________
If waiving medical benefits, please acknowledge by signing below: I understand that my health insurance may not cover any medical expenses for my injury and I may be held responsible for payment of medical expenses for my injury. ________________________________
If not represented by an Attorney, please acknowledge by signing below: I understand that I have a right to obtain an Attorney of my choice to review this Agreement and by signing below I acknowledge that I have waived that right. By waiving that right, I understand I will be held to the same standard as an Attorney and this Agreement will be enforceable as if represented by Attorney. ___________________________________________________________________________
__________________________________________ Attorney or representative for claimant (Signature) __________________________________________ Attorney or representative for claimant (Name typed) __________________________________________ Address __________________________________________ City, State, Zip
_______________________________________________ Claimant (Signature) _______________________________________________ Attorney or representative for employer (Signature) _______________________________________________ Address _______________________________________________ City, State, Zip
_______________________________________________ Attorney for Special Fund (Div. or Workers' Comp Funds)
DO NOT WRITE OR MARK BELOW THIS LINE
ORDER APPROVING 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