SETTLEMENT AGREEMENT AND APPLICATION FOR APPROVAL OF SETTLEMENT AGREEMENTBetter Workers' CompensationBuilt with you in mind.(FOR STATE FUND CLAIMS ONLY)This application should be filed to settle workers' compensation claims with state-fund employers. Ohio Revised Code 4123.65 requires that settlement applications be signed by both the injured worker and the employer, unless the employer is no longer doing business in Ohio. If the claim to be settled is a state-fund claim, and the employer is now self-insuring, the self-insuring employer will be charged dollar for dollar for any portion of the settlement attributed to past, present or future DWRF liability.By filing this application, the injured worker and the employer agree that all unresolved issues will be suspended. All ongoing compensation and medical payments, however, will continue until the effective settlement date. The effective settlement date is the mailing date of the BWC approval of settlement agreement. Please Note: After the effective settlement date, BWC will not pay for medical bills or services rendered, regardless of the dates of service generating such bills, whether or not the bills have been submitted to BWC, and whether or not the parties were aware of such bills.Special Notice to Medicare Beneficiaries Medicare does not pay medical bills for conditions covered by your workers' compensation claim. If a settlement of your workers' compensation claim is reached, and the settlement allocates certain amounts for future medical expenses (excluding amounts for prescription drugs), Medicare does not pay for those services until medical expenses related to your workers' compensation claim equal the amount of the lump sum settlement allocated to future medical expenses. For additional information, please call the Medicare Coordination of Benefits Contractor at 1-800-999-1118.COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.INSTRUCTIONS: For LOST TIME and MEDICAL ONLY claims mail this completed application to your nearest customer service office. Call 1-800-OHIOBWC for the address of your local customer service office. To settle a claim with a self-insuring employer, please complete and forward form SI-42, or contact your SI employer for other forms setting out the agreementCalendar No.between the injured worker and self-insuring employer. To facilitate settlement of this claim, please forward any unpaid bills to your Managed Care Organization.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)APPLICATION FOR APPROVAL OF SETTLEMENT AGREEMENT The injured worker and employer, as agreed to below, make application to the Ohio Bureau of Workers' Compensation (BWC) for approval of a final settlement in the injured worker's claim(s).PARTIES TO THE CLAIMInjured worker nameDate of birthPhone numberSocial Security NumberCityZIP code AddressState. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .I.D. numberInjured worker representative namePhone numberStateZIP code AddressCityTHE PEOPLE OF THE STATE OF NEW YORK TOFax numberPhone numberRisk numberEmployer nameZIP code AddressCityStateEmployer representative nameFax numberPhone numberGREETINGS:AddressZIP codeCityStateWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableInformation on other relevant employers is attachedYesNo,located at County ofCLAIM(S) TO BE INCLUDED IN SETTLEMENTo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomProposed Allocation of Requested Settlement AmountRequested Amount for Complete Settlement**Claim Number*IndemnityMedicalPrescription DrugsYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of the*List any claims specifically excluded from settlement: **Please explain any request for a partial settlement:Court in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Clearly set forth the circumstances by reason of which the proposed settlement is deemed desirable:Attorney(s) forOffice and P.O. AddressAre you receiving, or have you applied for Medicare benefits?Has information on other relevant claims been attachedYesNoYesNoWages at time of injury?Are you receiving medical treatment at this time?Who is your treating physician(s)?Telephone No.: Facsimile No.: E-Mail Address:NoYesAre you currently working? YesWhat are your present wages? What is your present occupation?If yes, who is your present employer?NoMobile Tel. No.:BWC-1372 (Rev. 7/9/2001) C-240American LegalNet, Inc. www.USCourtForms.comEMPLOYER SIGNATURE (Required by ORC 4123.65 unless the employer is no longer doing business in Ohio)INSTRUCTIONS: Please check one of the following boxes and sign below. Your signature does not waive the employer's right to withdraw consent to the settlement by providing written notice to the employee and the BWC administrator within 30 days after the administrator issues the approval of the settlement agreement.A. The employer agrees to the requested settlement terms. B. The employer does not agree with the requested settlement terms, but will participate with the BWC in the negotiation process. C. The employer is supportive of and agreeable to settlement of the claims listed on the front of this application. However, the employer will not participate in the settlement negotiations and requests the BWC to negotiate the settlement on behalf of the employer.D. The employer is not agreeable to settlement of the claim(s) listed on the front of this application.COURT COUNTY OFEmployer signatureTitleDate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Telephone numberFax number By signing this agreement, an employer that is currently self-insured acknowledges its obligation to reimburse BWC for the portion of the settlement amount allocated to DWRF costs of the above-referenced claim(s). The DWRF portion of the settlement will be billed to the self-insuring employer, even if the injured worker has not yet b
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