Pennsylvania > Workers Comp
Third Party Settlement Agreement LIBC-380 - Pennsylvania
| Third Party Settlement Agreement Form. This is a Pennsylvania form and can be used in Workers Comp . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
COMMONWEALTH OF PENNSYLVANIA THIRD PARTY Social Security Number: - -DEPARTMENT OF LABOR AND INDUSTRY BUREAU OF WORKERS COMPENSATION SETTLEMENT 1171 S. CAMERON STREET, ROOM 103 Date of Injury: / / HARRISBURG, PA 17104-2501 AGREEMENT MM DD YYYY (TOLL FREE) 800-482-2383 PA BWC Claim Number: (IF KNOWN)Employee Employer First Name Last Name Name _______________________________ ____________________________________________________________________________________________________________________ If Deceased - Dependent, Guardian Street 1 First Name Last Name ___________________________________________________________________________ _______________________________ _________________________________________Street 2 Street 1 ___________________________________________________________________________ ___________________________________________________________________________City/Town State Zip Code Street 2 __________________________________________ __________ __________-_______ ___________________________________________________________________________County City/Town State Zip Code _________________________________ __________________________________________ __________ __________-_______Telephone FEIN County Telephone (______) _______-_______________ _________________________ ___________________________________________ (______) _______-_______________ Insurer or Third Party Administrator (if self-insured) Name Employees Attorney ___________________________________________________________________________ Street 1 Name ___________________________________________________________________________ Street 2 ___________________________________________________________________________ Firm Name ___________________________________________________________________________ City/Town State Zip Code ___________________________________________________________________________ Street 1 __________________________________________ __________ __________-_______ Telephone Bureau Code ___________________________________________________________________________ Street 2 (______) _______-_______________ ____________________________ County ___________________________________________________________________________ City/Town State Zip Code ______________________________ Claim Number FEIN __________________________________________ __________ __________-_______ Telephone PA Attorney ID Number_________________________________________________________ (______) _______-________________________ ________________________________ Insurers Attorney Name ___________________________________________________________________________ Firm Name ___________________________________________________________________________ Street 1 ___________________________________________________________________________ Street 2 380 0505 ___________________________________________________________________________ City/Town State Zip Code __________________________________________ __________ __________-_______ Telephone PA Attorney ID Number (______) _______-________________________ ________________________________ LIBC-380 REV 5-05 (Page 1) (OVER) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 INSTRUCTIONS #1 -- Enter employees workers compensation rate. #2 -- Enter attorney fees and other expenses paid by the employee to obtain recovery in the third party action. #3 -- Enter the total amount of indemnity and medical bene ts paid by the employer to the employee at the time of the third party recovery. #4 -- Enter the total amount of money received by the employee from the third party litigation. #5 to #12 -- Perform the calculations in the right column and enter the results into the center column. In accordance with section 319 of the Pennsylvania Workers Compensation Act, parties herein have agreed to the following distribution of proceeds received from ________________________________________________________, third party: Calculation BASIC RECOVERY INFORMATION - Complete this section for all third party settlements. 1. Weekly Compensation Rate 2. Expenses of Recovery 3. Workers Compensation Accrued Lien 4. Total Amount of Third Party Recovery 5. Balance of Recovery --------------------------= #4 (minus) #3 PRESENT DISTRIBUTION OF PROCEEDS - Complete this section to calculate the amount of proceeds the employer is eligible to receive at the time the third party recovery takes place. 6, Accrued Lien Expense Reimbursement Rate --------------------------= #3 (divided by) #4 7. Expenses Attributable to Accrued Lien --------------------------= #2 (times) #6 8. Net Lien --------------------------= #3 (minus) #7 FUTURE DISTRIBUTION OF PROCEEDS - Complete this section to calculate how much the employer must reimburse the employee for expenses used to acquire the third party recovery during the Grace Period or when the employee receives future medical treatments. 9. Expense Reimbursement Rate --------------------------= #2 (divided by) #4 10. Grace Period --------------------------= #5 (divided by) #1 11. Expenses Attributable to Balance of Recovery --------------------------= #2 (minus) #7 12. Weekly Reimbursement of Expenses --------------------------= #11 (divided by) #10 Employees Signature Insurers Signature Employees Attorney Signature Insurers Attorney Signature DATE OF THIS AGREEMENT: ____/____/_______ MM DD YYYY Any individual ling misleading or incomplete information knowingly and with intent to defraud is in violation of Section 1102 of the Pennsylvania Workers Compensation Act and may also be subject to criminal and civil penalties through Pennsylvania Act 165 of 1994. Auxiliaryaidsandservicesareavailableuponrequesttoindividualswithdisabilities. EqualOpportunityEmployer/Program LIBC-380 REV 5-05 (Page 2) American LegalNet, Inc. www.USCourtForms.com
|
|||||||
