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Joint Petition And Stipulation K-WC 321 - Kansas

Joint Petition And Stipulation Form. This is a Kansas form and can be used in Workers Compensation .
 Fillable pdf Last Modified 8/1/2014
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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 Docket No. __________ AND Insurance Carrier JOINT PETITION AND STIPULATION Comes now the claimant, and by his attorney, ______________________, and respondent, (and its insurance carrier), by their attorney, ____________________________, (and the Kansas Workers' Compensation Fund by its attorney, ______________________). The parties represent and agree that the facts in the premises are as follows: 1. Claimant and respondent were operating under and subject to the provisions of the Kansas Workers Compensation Act at the time and as to the matters herein involved. Claimant elects to proceed under the provisions of the Kansas Workers Compensation Act and waives any rights that may exist under provisions of any other state's Workers Compensation Act for injuries covered by this Joint Petition and Stipulation. 2. On _______________, claimant met with personal injury by accident arising out of and in the course of employment with the respondent. The respondent had notice of the accidental injury. The claimant has made written claim for compensation on respondent as required by law. 3. The parties agree for the purpose of this settlement, that claimant's average weekly wage was $___________. 4. Claimant's injuries and disabilities are as set out in the attached medical report(s) of Dr. __________________ dated _______________. 5. Medical and hospital expenses have been incurred and paid as a result of this injury as set out in the attached itemized list in the total amount of $____________. The respondent/insurance carrier will pay all valid and authorized medical and hospital expenses up to the date of the signing of this Joint Petition and Stipulation. After the date of said signing, any future medical or hospital expenses will be the obligation of the claimant. 6. The following medical expenses were incurred but are not included in the list of paid medical expenses. These expenses will be paid by ___________________. 7. Claimant has received _____ weeks of temporary total disability compensation paid at $_______ per week in the sum of $______________. K-WC 321 (Rev. 6-13) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Sample of claim settled with claimant (Feel free to make changes where appropriate) Docket No. __________ 8. Claimant has read this Joint Petition and Stipulation together with the medical reports attached hereto and has had the same fully explained to him. 9. Said settlement is in the amount of $___________ representing an approximate ____ percent permanent partial general bodily disability (or ____ percent loss of use). OR 9. Compensation is being paid for _____ weeks temporary total disability at $______ per week in the sum of $___________ and _______ weeks of permanent partial compensation at $_________ per week in the sum of $___________ for a _____ percent permanent partial general bodily disability (or ____ percent of loss of use), making a total award of $_______________. 10. Claimant understands that this settlement is a full and final settlement of any workers compensation claim he has against the respondent/carrier for the above mentioned accident. Claimant further understands and agrees that he waives any right to vocational rehabilitation benefits under the Kansas Workers Compensation Act herein and states and advises the Director that it is in his best interest to have a lump sum settlement of this matter as per the above agreement. The parties stipulate and agree that they are waiving all rights to appeal (or review and modify) this award after the date of this award being entered. This is a full and final settlement of all claims herein. The parties hereby waive notice and formal hearing herein and request the Workers Compensation Director issue an award approving this settlement of compensation and medical expenses made by reason of the facts set forth herein and that the costs be taxed to the respondent. Claimant resides in __________________(city), ______________(state), and it would be a hardship to return to the state of Kansas for a settlement hearing. Wherefore, the parties request that the Director issue an award in conformity with the above stipulations. ____________________________________ Claimant's name and address (Signature shall be notarized) _____________________________________ Attorney for claimant and address Supreme Court No. __________ _____________________________________ Respondent's name and address By: _________________________________ K-WC 321 (Rev. 6-13) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
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