Settlement Agreement And Application For Approval Of Settlement Agreement {BWC-1372}

BWC-1372 / C-240 - SETTLEMENT AGREEMENT AND APPLICATION FOR APPROVAL OF SETTLEMENT AGREEMENT. You must file this form when requesting a settlement. In addition: If you are an injured worker receiving permanent total disability (PTD) benefits, an injured worker who is requesting consideration for PTD benefits, or a claimant currently receiving death benefits, you must complete and submit with this settlement application: – Medical History and Disclosure (C-242) with supporting medical documentation and; If applying for full settlement the: – PTD-Death Settlement Acknowledgment and Waiver (C-243) or; If applying for an indemnity only settlement the: – Indemnity Only Settlement Acknowledgment and Waiver (C-245). If you are an injured worker applying for an indemnity only settlement, you must complete and submit with this settlement application: – Indemnity Only Settlement Acknowledgment and Waiver (C-245). You must submit required information listed above to avoid delays in processing and/or disapproval of the application. BWC may request that an injured worker submit the C-242 with supporting medical documentation for claims other than those listed above. By fling this application, the claimant and the employer understand BWC will suspend all unresolved claim issues, except issues related to temporary total benefits, PTD benefits, and alternative dispute resolutions, which BWC will continue to process. This application can only be used to settle a claim(s) with a single employer. If you wish to settle claims assigned to a different employer, you must file a separate application. Use a Self-insured Joint Settlement Agreement and Release (SI-42) to pursue a settlement with a self-insuring employer. Submit this form, via fax, or send it to your local BWC customer service office. www.FormsWorkflow.com