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Recoveries And Settlements Form F800-074-000 - Washington

Recoveries And Settlements Form Form. This is a Washington form and can be used in Crime Victims Compensation Workers Comp .
 Fillable pdf Last Modified 11/17/2011
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Read completely before filling out the enclosed form. We sent you this form because you may take legal action against any party liable for your injury. By law, we have a right to be reimbursed for any expenses paid, if you receive money from a settlement. Questions? Call: 1-800-762-3716 Write: Know What to Expect: How recoveries and settlements may impact your crime victim claim Third party A liable party is called a "third party" ­ someone who caused or contributed to your injury. Examples: n n n Special Claims Unit Crime Victims Compensation Program Department of Labor & Industries PO Box 44520 Olympia, WA 98504-4520 Visit: www.CrimeVictims.Lni.wa.gov and click on Recoveries and Settlements Information The driver of the car that hit you. The tavern that over-served the drunk driver. The owner of the business where the crime occurred who may be negligent. The person who assaulted you. n First party The Crime Victims Compensation Program is the last payer of benefits. All other insurance must be used first. You must file a claim with your own insurance. Examples of "first party" are: n n n n Auto insurance. Homeowners insurance. Life insurance. Umbrella policy (additional coverage for losses above the limits of underlying policies such as auto, boat, rental, homeowners or business insurance policies). Other formats for persons with disabilities are available on request. Call 1-800-547-8367. TDD users, call 360-902-5797. L&I is an equal opportunity employer. Complete and return the enclosed form within 30 days. PUBLICATION F800-074-000 [05-2009] American LegalNet, Inc. www.FormsWorkFlow.com What the law requires when you receive a settlement n You n We How excess recovery affects payments of benefits n We Choosing Option A or Option B on the recoveries and settlement form Complete Option A if you intend to pursue or you are already pursuing legal action against a third party or with your own insurer (first party). You and your attorney, if you have hired one, must notify us when you file your lawsuit and keep us informed of its progress. or your representative must notify us of any settlement offered. are reimbursed a portion of expenses paid on the claim. will pay benefits when there is no more excess recovery on your claim. health-care provider must bill us and use our billing forms and fee schedule. will: n Your n We How the settlement is distributed Funds are distributed according to a formula set by Washington law. n You n n Determine the amount payable. Reduce the excess recovery by the amount payable. Send your health-care provider a statement (remittance advice) showing the amount you owe. Send you a letter showing the amount you must pay. n are entitled to 25% of the net amount you receive after reasonable attorney fees and costs, if any. must reimburse us for expenses paid on the claim. settlement money remaining after you receive your 25% and we receive our portion is considered an offset toward future benefits. This remaining amount is called "excess recovery." n Complete Option B if you do not want to take legal action against a third party or your insurer. We may decide to take legal action against the third party or with your insurer. If we do take legal action, you will not pay any legal fees. Fees are deducted from settlements, but if no settlement is made, no fees are required. You will receive a portion of any recovery made, if we recover settlement funds from the party or parties responsible for your injuries as a result of the crime. n You n You n Any will pay your health-care provider the amount due. Important Note! By law, your health-care provider can't bill you the difference between the amount they charge and the rate we pay. What happens if you receive a settlement before your claim is allowed. If you receive money from a settlement before your claim is allowed, it may impact whether we can pay benefits. If you would like more information, call 1-800-762-3716 and ask to speak with a Recovery Adjudicator. American LegalNet, Inc. www.FormsWorkFlow.com Special Claims Unit Crime Victims Compensation Program Department of Labor & Industries PO Box 44520 Olympia WA 98504-4520 Fax: 360-902-5333 Recoveries and Settlements Form Crime Victim: You have legal options. Carefully read the attached brochure and complete this form. Check either Option A or Option B below. Sign, date and then mail back the form. Write your name and your claim number below. Victim Name Claim Number My address has changed. Check the box and write your NEW address below. Victim Mailing Address City State Zip Make your choice. Then sign and my in the appropriate place. My attorney or I will seek to recoverdatepersonal injury damages. My attorney or I will seek to recover damages for my crime injury. Option A: I understand that I must notify the Crime Victims Compensation Program (CVCP) if or when I file a lawsuit or expect to receive a settlement. If I choose to hire an attorney, I give the CVCP permission to communicate with him or her. I also understand that if I receive money as a result of a legal settlement or award, I must repay the CVCP for benefits paid on my crime victim claim. If I have an attorney, I have provided his or her name, address and telephone number below. Date Signature X Attorney's Name Attorney's Address Attorney's Phone Number ( ) City State Zip Option I authorize the CVCP to consider recovery damages for my crime injury. I give up my right to take legal action against a liable party, on my own or with an attorney. I give this right to the CVCP. I understand the CVCP may chose to not take legal action. I authorize the CVCP to release information from my claim file for these purposes. I have not received any money from any liable party for my crime injury. Date B: Signature X After you complete and sign this form, detach this form from the accompanying brochure. Fold it with the Business Reply Mail side facing out. Use tape to close the form, and then mail. No postage is needed. American LegalNet, Inc. www.FormsWorkFlow.com F800-074-000 [05-2009]
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