Agreement As To Compensation Injury {110I}

FORM 110-I - AGREEMENT AS TO COMPENSATION AND ORDER APPROVING SETTLEMENT. This form is used in Kentucky workers’ compensation cases to document and approve an injury settlement between an employee, employer, and insurer. It records key details such as the claimant’s information, nature of injury, medical expenses, impairment ratings, work history, and wages. The form also specifies benefit amounts, temporary or permanent disability compensation, and whether payments will be made in lump sum or installments. It provides space for medical waivers, Medicare Set Aside information, and acknowledgment of rights related to medical benefits, including the 780-week limit. Signatures from the claimant, employer, and attorneys (if applicable) are required, and the settlement becomes enforceable once approved by an Administrative Law Judge. www.FormsWorkflow.com