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Agreement As To Compensation And Order Approving Settlement (Occupational Disease) 110-O - Kentucky
| Agreement As To Compensation And Order Approving Settlement (Occupational Disease) Form. This is a Kentucky form and can be used in Workers Comp . |
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FORM 110-O KENTUCKY DEPARTMENT OF WORKERS CLAIMS HEARING LOSS/ OCCUPATIONAL DISEASE Frankfort, KY 40601 Revised June, 2000 AGREEMENT AS TO COMPENSATION AND ORDER APPROVING SETTLEMENT Workers Compensation Claim No. ____________________ IF THIS FORM IS NOT PROPERLY COMPLETED, IT WILL BE RETURNED. Every section should be filled in. If a section is not applicable, fill in the blank with N/A. Claimant Insurer/Self-Insured/Self-Insurance Group Social Security Number Date of Birth Insurers Address Address City, State Zip Code City, State, Zip Code Employer Other participating parties Address Address City, State, Zip Code City, State, Zip Code HEARING LOSS OR OCCUPATIONAL DISEASE : INJURIOUS EXPOSURE Occupational disease: Cause of disease: Date of last exposure: County in which exposure occurred: Brief description of history of exposure: Body part(s) affected: Length of exposure: MEDICAL INFORMATION Medical expenses paid: $ Date of last medical payment: Medical expenses unpaid or contested: $ Surgery performed: Yes No Nature of surgery: Hospitalization(s): Yes No Length of hospital stay(s): Impairment ratings: (Attach entire medical report that provides ratings) Date Given Physician % % % Restrictions on activities -- Attach most recent medical report setting forth physical restrictions.Diagnosis or diagnoses: If medical treatment is continuing, attach a copy of executed Form 113 indicating designatedphysician. WORK INFORMATION <<<<<<<<<********>>>>>>>>>>>>> 2Type of work at last exposure: Average weekly wage at time of last exposure: $ Date of return to work: Wages upon return to work:$ Type of work performed after return: Type of work performed at time of settlement: BENEFIT AND SETTLEMENT INFORMATION Amount and duration of temporary total disability paid to date: $ X = Per week No. of weeks TotalMonetary terms of settlement: $ , to be paid as follows: ___ lump sum , ___ weekly for weeks, ____ by annuity, ___ other Total settlement amount: $ Percent of permanent disability: %Settlement computation: Does settlement amount include waiver or buyout of past or future medical expenses? Yes No. If yes, settlement amount for waiver or buyout: $ If settlement terms provide for lump sum representing weekly benefits greater than $100, doesclaimant have an adequate source of income during disability? Yes NoSource of income: Amount: $ Does settlement include retraining incentive benefits? Yes NoIf yes, is claimant actively participating in instruction or training program? Yes NoName of instruction or training program (Attach additional pages if necessary): OTHER INFORMATION If additional information is pertinent to settlement, explain, (Attach additional pages if necessary): Other responsible parties against whom further proceedings are reserved: This the day of , 20 . Attorney or representative for claimant (Signature) Claimant (Signature) Attorney or representative for claimant (Name typed) Attorney or representative for employer Address Address City, State, Zip City, State, Zip Attorney for Special Fund ORDER APPROVING SETTLEMENT AGREEMENT IT IS ORDERED that the above Agreement as to Compensation be and the same in hereby APPROVED. This the day of , 20 . Administrative Law Judge
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