Free K-WC D - Final Release (Rev. 01-09) - Kansas

KANSAS DEPARTMENT OF LABOR www.dol.ks.gov

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SETTLEMENT AGREEMENT FINAL RECEIPT AND RELEASE OF LIABILITY
K-WC Form D (Rev. 01-2009)

TheKansasWorkersCompensationlawprovidesthatcompensationduemaybesettledbyagreementand thattheemployerisentitledtoareceiptandreleaseofliabilityuponfinalpaymentofcompensationdue, andthatsuchfinalreceiptandreleaseofliabilityshallbefiledbytheemployerintheofficeoftheDirector ofWorkersCompensationwithinsixty(60)daysafterthedateoftheexecutionofthesame,andthatsuch agreement,finalreceiptandreleaseofliabilityismadesubjecttotheapprovaloftheDirectorthatthecorrect amountofcompensationhasbeenpaidasrequiredbylaw,andwillautomaticallybecomeapprovedbylaw unlessdisapprovedbytheDirectorwithintwenty(20)daysofthedateitisreceivedbythatoffice.

COMPLETION OF THIS REPORT IS REQUIRED BY LAW.
51-3-2 Final receipt and release of liability.Afinalreceiptandreleaseofliabilityshallcoverall compensationpaidandshallnotbetakenuntilthedisabilityhasterminated,orincaseofpermanentpartial disability,untilafinaldeterminationofthepercentageofthatpermanentpartialdisabilitycanbedefinitely ascertained.Nocompromisesettlementsshallbemadeonafinalreceiptandreleaseofliability.The physician'sreportorreportsaccompanyingthefinalreceiptandreleaseofliabilityshallconformtotheamount paidforthedisabilityexceptwhentheratingisanaverageoftheratingsexpressedbythedoctors. Datesandfiguresrequiredshallbespecificandaccurate,andonlyinexceptionalinstanceswhereexplanation isnecessarymayinsertionsoradditionsbemade. Thefinalreceiptandreleaseofliabilityshallbesignedbytheclaimant,andthesignatureshallbenotarized. Thefinalreceiptandreleaseofliabilityformshallbeaccompaniedbyaphysician'sfinalreportandbyan accidentreportifthereporthasnotalreadybeenfiledwiththedivisionofworkerscompensation. (AuthorizedbyK.S.A.44-573;implementingK.S.A.44-527;effectiveJan.1,1966;amendedJan.1,1973; amendedFeb.15,1977;amendedMay1,1978;amendedMay1,1983;amendedJune21,2002.) NOTE (1):Aphysician'sfinalreportmustaccompanythisagreementwhenitisfiledwiththeDirectorforapproval. NOTE (2):Nocompensationotherthanmedicalispayableforthefirstweekfollowingtheinjury,exceptcasesof amputationordeath,unlesstemporarytotallosscontinuesforthreeconsecutiveweeks.

Federal Privacy Act Disclosure Section 7(a)(2)(B)
ThemandatoryrequirementthatsocialsecuritynumbersbeincludedonformsfiledwiththeDivisionofWorkersCompensation ispermittedbySection7(a)(2)(B)oftheFederalPrivacyActof1974,sinceourregulationswhichrequireitsdisclosurewerein existencebeforeJanuary1,1975.ThenumberisusedasameansofidentifyingallthevariousrecordsintheDivisionofWorkers Compensationpertainingtoanindividual. Theuseofsocialsecuritynumbersismadenecessarybecauseofthelargenumberofapplicantswhohavesimilarnames andbirthdates,andwhoseidentitiescanonlybedistinguishedbythesocialsecuritynumber.

DivisionofWorkersCompensation 800S.W.JacksonStreet,Suite600,Topeka,KS66612-1227 Phone:(785)296-2996·Fax(785)296-0025·E-mail:[email protected]

KansasDepartmentofLabor

SETTLEMENT AGREEMENT ­ FINAL RECEIPT AND RELEASE OF LIABILITY
K-WC Form D (Rev. 01-2009)

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1. Employer'sname____________________________________________________________________________________________________________ Address: Street______________________________________________ City________________________State_____________ZIP_____________

2. Insurancecarrier___________________________________________________________Phone_________________________________(Ext.)____________________ Address________________________________________________________________________________Ins.Co.FileNo.____________________

3. Injuredworker___________________________________________________________SocialSecurityNumber_______________________________ Address: Street_________________________________________________ City________________________ State_____________ ZIP_____________

4. Natureofinjuryforwhichthisclaimforcompensationismade________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Compensation paid on the following basis: 12. _______weeks______days temporarytotaldisability ............................................ $________________ 13. _______weeks______days _______%temporarypartialdisability @_______________________perweek ................. $________________ 14. _______weekspermanentpartialdisabilityfor: Percentofamputationto _____________________ _________________________________________ _______%lossofuseof_____________________ $________________

5. Dateofinjury____________________________________________ 6. Lastdayemployeeworked_________________________________ 7. Dateemployeewasabletoreturntowork ______________________________________________________

8. Date employee returned to work____________________________ 9. Ifemployeeworkedbetweendateofinjuryandlastdateofdisability, give dates_____________________________________________ ______________________________________________________

TOTAL COMPENSATION ................................................ $________________ 15. Hospitalexpense ....................................................... $________________ 16. Medicalexpense ....................................................... $________________ 17. Other(specify)_____________________________ $________________ TotalMedical ............................................................. $________________

10. Averageweeklywage$___________________________________ 11. Weeklycompensationrate$________________________________ NOTE: No compromise settlements shall be made on a final receipt and release of liability.

18. IsthisaReleaseandReceiptforpaymentsmadeonawardofDirector?________________________________________________________________ Ifhearing(s)held,givedateandplaceofhearing(s)_________________________________________________________________________________

FINAL RECEIPT AND RELEASE OF LIABILITY
Receivedfrom(nameofemployerorinsurancecarrier)_____________________________________________________________________________ thesumof_______________________________________________________($_________________________________)makinginall,withpayments alreadyreceivedatotalsumof_______________________________________________________________($_______________________________) INFINALRECEIPTANDRELEASEOFLIABILITYofthisclaimforcompensationandanyotherclaimsforcompensationheretoforemadeonaccountof anyandallinjuriesanddisabilityincurredbyreasonoftheaccidentreferredtointhisinstrument. SIGNED,ACKNOWLEDGEDANDAGREEDbyEmployerandWorkerthis______________________dayof____________________A.D.,20_______ _______________________________________________________________________________________________________________________ EmployerorAgentofemployerandinsurancecarrier Worker JURAT StateofKansas,Countyof______________________________ss. BEITREMEMBERED,thatonthis______________________dayof_______________________,20____,beforeme,theundersigned,aNotaryPublic inandforsaidcountyandstate,cametheabovenamedworker,tomepersonallyknowntobethesamepersonwhosigned,acknowledgedandagreed totheforegoinginstrumentofwritinganddulyacknowledgedthatheunderstoodandexecutedthesameasofthedateabovewritten. Mycommissionexpires: _________________________________ NotaryPublic:_________________________________________

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KansasDepartmentofLabor

SETTLEMENT AGREEMENT ­ FINAL RECEIPT AND RELEASE OF LIABILITY
K-WC Form D (Rev. 01-2009)

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Initial Below

WAIVER OF RIGHTS

____1. IamawareIhavetherighttoahearingbeforeanAdministrativeLawJudgewhereImayreceiveanawardofmore, lessorthesameamountofmoneythatIamreceivinginthissettlement.BysettlingthiscaseIgiveupmyrighttoa hearing. ____2. IfIdonotlikethedecisionofthatjudge,IhavearighttoappealthedecisiontotheKansasWorkersCompensation Board.BysettlingthiscaseIgiveupmyrighttoanappeal. ____3. BygivingupmyrighttoatrialbeforeanAdministrativeLawJudge,Iunderstandthatifmyconditionworsens,I cannotlateraskthecourttoincreasetheamountofmoneyawardedandreceived. ____4. IunderstandthatIamgivingupmyrighttoanymoremedicaltreatmentrelatedtothisinjury.IunderstandIwillbe responsibleforunpaidmedicalbills,eveniftheyarerelatedtothisinjury,thatarenotincludedintheSettlement AgreementFinalReceiptandReleaseofLiability(FormD)ormedicaltreatmentexpensesincurredaftertoday'sdate relatingtothisinjury.

____5. IunderstandIamgivingupmyrighttousemy$500.00forunauthorizedmedicalexpensestoobtainasecond opinion,butnotarating,fromanydoctorthatIchooseformedicalconditionsrelatedtothisinjury.

____6. Iunderstandthateventhoughadoctorreleasesmeand/orprovidesanimpairmentratingtomyemployer,Iamnot requiredtogiveupanyrightthatIhaveundertheKansasWorkersCompensationAct. ____7. Ihaveread,orhavehaditreadtome,andfullyunderstandmyimpairmentand/ordisabilityrating. ____8. IhavereadandunderstandthemedicalreportsattachedtothisFormD,orhavehadthemedicalreportsreadtome. ____9. IhavereadandunderstandtheFormDentirely,orhavehaditreadtome.Iagreethatthefactscontainedtherein aretrueandacccurateandunderstandthetermsofthesettlement.Ibelievethatthissettlementisinmybestinterest andwantthisFormDapprovedbytheDivisionofWorkersCompensation.

_____________________________________ Worker

CERTIFICATION
Stateof________________________,Countyof_________________________ss. BEITREMEMBEREDthatonthis________dayof_____________________,20____,beforemetheundersigned,a NotaryPublicinandforsaidcountyandstate,cametheabovenamedworker,tomepersonallyknowntobethesame personwhosigned,acknowledgedandagreedtotheSettlementAgreementFinalReceiptandReleaseofLiability (FormD)anddulyacknowledgedthatheunderstoodandexecutedthesameasofthedateabovewritten. Mycommissionexpires:___________________________ NotaryPublic:___________________________________