FORM 110-O HRNG LOSS/OCC DIS Revised July, 2006
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 completed. If a section if 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
HEARING LOSS OR OCCUPATIONAL DISEASE: INJURIOUS EXPOSURE
Occupational disease: ______________________________________ Cause of disease:_______________________________ Date of last exposure: ___________________________________County in which exposure occurred:____________________ Brief description of history of exposure______________________________________________________________________ ______________________________________________________________________________________________________ Body part(s) affected:_____________________________________ Length of exposure:______________________________
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.
Type of work at last exposure:_____________________________________________________________________________ Average weekly wage at time of last exposure: $_____________________ Date of return to work:_______________________ Wages upon return to work: $____________ Type of work performed after return:____________________________________ 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 [email protected] $___________ * _________=$_______________ (MM/DD/YR) (MM/DD/YR) Amount # of wks Total Monetary terms of settlement: ____________, paid in lump sum:______________, or weekly for _________ weeks Settlement computation:__________________________________________________________________________________ TTD*IMP RATING*AMA FACTOR*RTW FACTOR*DISC FACTOR OR # OF WKS=TOTAL Amount of Waiver(s) Please circle: Waiver or buyout of past medical benefits Waiver of 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:______________ Lump Sum Periodic Payments: ___________*_____________*______________ = _______________________ Amount Frequency Duration Total 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: $__________________ Does settlement include retraining benefits? Yes No If yes, is claimant actively participating in instruction or training program? Yes No Name of instruction or training program (Attach additional pages if necessary):__________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
OTHER INFORMATION If additional information is pertinent to settlement, explain, (Attach additional pages if necessary): _____________________________________________________________________________________ _____________________________________________________________________________________ Other responsible parties against who 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. _______________________________________________ Claimant (Signature)
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 the 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. ________________________________________________ Claimant (Signature)
________________________________________________ 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)
This the ________ day of ____________, 20_____.
DO NOT WRITE OR MAKE 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______.