Kansas > Workers Compensation

Award On Joint Petition And Stipulation K-WC 322 - Kansas

Award On Joint Petition And Stipulation Form. This is a Kansas form and can be used in Workers Compensation .
 Fillable pdf Last Modified 8/1/2014
Get this form for FREE as a print-only pdf

Sample of claim settled with claimant (Feel free to make changes where appropriate) BEFORE THE DIVISION OF WORKERS COMPENSATION STATE OF KANSAS ) ) ) ) ) ) ) ) ) ) ) ) ) S.S. # Claimant VS. Respondent AND Docket No. __________ Insurance Carrier AWARD ON JOINT PETITION AND STIPULATION Now on _____________________, the above entitled matter comes on for consideration for an award on the Joint Petition and Stipulation filed by the parties herein, and the Director, having fully considered said Joint Petition and Stipulation, is of the opinion that an award should be issued in compliance with the terms of settlement set out therein. WHEREFORE, AN AWARD OF COMPENSATION IS HEREBY MADE in favor of the claimant, ______________, and against the respondent, ______________________, and its insurance carrier, ________________________, for _______ weeks of temporary total disability compensation at the rate of $________ per week in the sum of $_______________ which has heretofore been paid, plus a settlement in the amount of $__________________, for a ______ percent permanent partial disability to the body as a whole (or disability to the ______________ [scheduled member]) and this amount by request and consent of all parties as shown by the record, is hereby ordered paid in one lump sum in full and final settlement of any and all claims for any and all disability incurred by claimant relative to the accidental injury of __________________________. FURTHER AWARD IS MADE that respondent and insurance carrier pay medical and hospital expenses as listed in Item #_____ of said Joint Petition and Stipulation in the total amount of $___________, which expenses have heretofore been paid, plus any and all valid and authorized medical expenses up to the date of the signing of said Joint Petition and Stipulation. Costs herein, if any, are hereby taxed to the respondent. Filed in the Kansas Division of Workers Compensation on _______________________. ___________________________________ WORKERS COMPENSATION DIRECTOR Copies to: K-WC 322 (Rev. 6-13) American LegalNet, Inc. www.FormsWorkFlow.com
Link/Embed this Document

Popular Searches

  1. Civil Case Cover Sheet
  2. modification of child support
  3. default
  4. claim of exemption
  5. petition for summary administration
  6. cover sheet
  7. continuance
  8. settlement
  9. proof of service by mail
  10. Unlawful Detainer

Bookmark and Share