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Settlement Agreement Final Receipt And Release Of Liability K-WC Form D - Kansas

Settlement Agreement Final Receipt And Release Of Liability Form. This is a Kansas form and can be used in Workers Compensation .
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KANSAS DEPARTMENT OF LABOR www.dol.ks.gov Page 1 of 3 K-WC Form D (Rev. 3-14) SETTLEMENT AGREEMENT ­ FINAL RECEIPT AND RELEASE OF LIABILITY MAIL:DivisionofWorkersCompensation 401SWTopekaBlvd.,Suite2 Topeka,KS66603-3105 FAX:(785)296-8580 TheKansasWorkersCompensationlawprovidesthatcompensationduemaybesettledbyagreementand thattheemployerisentitledtoareceiptandreleaseofliabilityuponfinalpaymentofcompensationdue, andthatsuchfinalreceiptandreleaseofliabilityshallbefiledbytheemployerintheofficeoftheDirector ofWorkersCompensationwithinsixty(60)daysafterthedateoftheexecutionofthesame,andthatsuch agreement,finalreceiptandreleaseofliabilityismadesubjecttotheapprovaloftheDirectorthatthecorrect amountofcompensationhasbeenpaidasrequiredbylaw,andwillautomaticallybecomeapprovedbylaw unlessdisapprovedbytheDirectorwithintwenty(20)daysofthedateitisreceivedbythatoffice. COMPLETION OF THIS REPORT IS REQUIRED BY LAW. 51-3-2 Final receipt and release of liability.Afinalreceiptandreleaseofliabilityshallcoverall compensationpaidandshallnotbetakenuntilthedisabilityhasterminated,orincaseofpermanentpartial disability,untilafinaldeterminationofthepercentageofthatpermanentpartialdisabilitycanbedefinitely ascertained.Nocompromisesettlementsshallbemadeonafinalreceiptandreleaseofliability.The physician'sreportorreportsaccompanyingthefinalreceiptandreleaseofliabilityshallconformtotheamount paidforthedisabilityexceptwhentheratingisanaverageoftheratingsexpressedbythedoctors. Datesandfiguresrequiredshallbespecificandaccurate,andonlyinexceptionalinstanceswhereexplanation isnecessarymayinsertionsoradditionsbemade. Thefinalreceiptandreleaseofliabilityshallbesignedbytheclaimantandthesignatureshallbenotarized. Thefinalreceiptandreleaseofliabilityformshallbeaccompaniedbyaphysician'sfinalreportandbyan accidentreportifthereporthasnotalreadybeenfiledwiththeDivisionofWorkersCompensation. (AuthorizedbyK.S.A.44-573;implementingK.S.A.44-527;effectiveJan.1,1966;amendedJan.1,1973; amendedFeb.15,1977;amendedMay1,1978;amendedMay1,1983;amendedJune21,2002.) NOTE (1):Aphysician'sfinalreportmustaccompanythisagreementwhenitisfiledwiththeDirectorforapproval. NOTE (2):Nocompensationotherthanmedicalispayableforthefirstweekfollowingtheinjury,exceptcasesof amputationordeath,unlesstemporarytotallosscontinuesforthreeconsecutiveweeks. Federal Privacy Act Disclosure Section 7(a)(2)(B) ThemandatoryrequirementthatSocialSecuritynumbersbeincludedonformsfiledwiththeDivisionofWorkers CompensationispermittedbySection7(a)(2)(B)oftheFederalPrivacyActof1974,sinceourregulationswhich requireitsdisclosurewereinexistencebeforeJanuary1,1975.Thenumberisusedasameansofidentifying allthevariousrecordsintheDivisionofWorkersCompensationpertainingtoanindividual. TheuseofSocialSecuritynumbersismadenecessarybecauseofthelargenumberofapplicantswhohave similarnamesandbirthdates,andwhoseidentitiescanonlybedistinguishedbytheSocialSecuritynumber. DIVISION OF WORKERS COMPENSATION 401SWTopekaBlvd.,Suite2,Topeka,KS66603-3105·Phone:(785)296-4000·Fax:(785)296-8580 American LegalNet, Inc. www.FormsWorkFlow.com KansasDepartmentofLabor K-WC Form D (Rev. 3-14) Settlement Agreement ­ Final Receipt and Release of Liability Page2of3 1. Employer'sname:___________________________________________________________________________________________________________ Address:Street__________________________________________________City_______________________State______________ZIP _____________ Address:________________________________________________________________________________ Ins.Co.FileNo.:___________________ Address:Street_________________________________________________City_________________________State____________ZIP _____________ __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ Compensation paid on the following basis: 12. _______weeks______days Temporarytotaldisability ........................................... $________________ 13. _______weeks______days _______%temporarypartialdisability 14. @_______________________perweek ................. $________________ _______weekspermanentpartialdisabilityfor: Percentofamputationto _____________________ _________________________________________ _______%lossofuseof_____________________ $________________ 2. Insurancecarrier:___________________________________________________________Phone:_________________________(Ext.)____________ 3. Injuredworker:_______________________________________________________________ SocialSecuritynumber:__________________________ 4. Natureofinjurybyaccident,repetitivetraumaordiseaseforwhichthisclaimforcompensationismade: ______________________________________ _ 5. Date(s)ofinjurybyaccident,repetitivetraumaordisease: _______________________________________________________ 6. Lastdayemployeeworked: _________________________________ 7. Dateemployeewasabletoreturntowork:_____________________ 8. Dateemployeereturnedtowork: _____________________________ 9. Ifemployeeworkedbetweendate(s)ofinjurybyaccident,repetitive traumaordiseaseandlastdateofdisability,givedates: _______________________________________________________ _______________________________________________________ 10. Averageweeklywage: $___________________________________ 11. Weeklycompensationrate: $_______________________________ NOTE: No compromise settlements shall be made on a final receipt and release of liability. TOTAL COMPENSATION ................................................ $________________ 15. Hospitalexpense ....................................................... $________________ 16. Medicalexpense ....................................................... $________________ 17. Other(specify):_____________________________ $________________ Total Medical ............................................................ $________________ 18. IsthisaReleaseandReceiptforpaymentsmadeonawardofDirector?_________________________________________________________________ Ifhearing(s)held,givedate(s)andplace(s)ofhearing(s):____________________________________________________________________________ __________________________________________________________________________________________________________________________ FINAL RECEIPT AND RELEASE OF LIABILITY Receivedfrom(nameofemployerorinsurancecarrier) ___________________________________________________________________
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