Delaware > Workers Compensation
Petition For Commutation 16 - Delaware
| Petition For Commutation Form. This is a Delaware form and can be used in Workers Compensation . |
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P E T I T I O N F O R C O M M U T A T I O N _________________ TO THE INDUSTRIAL ACCIDENT BOARD OF THE STATE OF DELAWARE SITTING IN AND FOR COUNTY ) Employer, ) SS# Carrier File # ) vs. ) ) Carrier/Self-Insurer Name ) Claimant. ) ) Date of Injury Hearing No. The undersigned prays that your Honorableard Boshall, after due notice of the time and place of hearing served on all parties in interest, hear and determine the matter in accordance with the facts and the law, and state iconclusiots ns of fact and rulings of law. Petition for Commutation of Bneefits, Pursuant to 2358: (Please check the appropriate block(s) ) Total Disability Partial Disability Pursuant to 2324 Pursuant to 2325 Permanent Partial All Benefits Except Pursuant to 2326 Medical Expenses 2ND Injury Fund Other Pursuant to 2327 Petition for Commutation of Bneefits, Pursuant to 2358: The Parties Agree to the Above Settlement Commutation to be Presented by Stipulation to the Board. The Person Who the Parties Agreed With is ________________________________________________________________ . The Parties Contest the Above Commutation and Request a Pre-trial Hearing. Date this day of A.D. 20 . N ame Address Form 16 Document No. 60-07-01-90-09-01
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