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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. 6-12) SETTLEMENT AGREEMENT ­ FINAL RECEIPT AND RELEASE OF LIABILITY The Kansas Workers Compensation law provides that compensation due may be settled by agreement and that the employer is entitled to a receipt and release of liability upon final payment of compensation due, and that such final receipt and release of liability shall be filed by the employer in the office of the Director of Workers Compensation within sixty (60) days after the date of the execution of the same, and that such agreement, final receipt and release of liability is made subject to the approval of the Director that the correct amount of compensation has been paid as required by law, and will automatically become approved by law unless disapproved by the Director within twenty (20) days of the date it is received by that office. COMPLETION OF THIS REPORT IS REQUIRED BY LAW. 51-3-2 Final receipt and release of liability. A final receipt and release of liability shall cover all compensation paid and shall not be taken until the disability has terminated, or in case of permanent partial disability, until a final determination of the percentage of that permanent partial disability can be definitely ascertained. No compromise settlements shall be made on a final receipt and release of liability. The physician's report or reports accompanying the final receipt and release of liability shall conform to the amount paid for the disability except when the rating is an average of the ratings expressed by the doctors. Dates and figures required shall be specific and accurate, and only in exceptional instances where explanation is necessary may insertions or additions be made. The final receipt and release of liability shall be signed by the claimant and the signature shall be notarized. The final receipt and release of liability form shall be accompanied by a physician's final report and by an accident report if the report has not already been filed with the Division of Workers Compensation. (Authorized by K.S.A. 44-573; implementing K.S.A. 44-527; effective Jan. 1, 1966; amended Jan. 1, 1973; amended Feb. 15, 1977; amended May 1, 1978; amended May 1, 1983; amended June 21, 2002.) NOTE (1): A physician's final report must accompany this agreement when it is filed with the Director for approval. NOTE (2): No compensation other than medical is payable for the first week following the injury, except cases of amputation or death, unless temporary total loss continues for three consecutive weeks. Federal Privacy Act Disclosure Section 7(a)(2)(B) The mandatory requirement that Social Security numbers be included on forms filed with the Division of Workers Compensation is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, since our regulations which require its disclosure were in existence before January 1, 1975. The number is used as a means of identifying all the various records in the Division of Workers Compensation pertaining to an individual. The use of Social Security numbers is made necessary because of the large number of applicants who have similar names and birth dates, and whose identities can only be distinguished by the Social Security number. DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone: (785) 296-4000 · Fax: (785) 296-8580 · Email: wc@dol.ks.gov American LegalNet, Inc. www.FormsWorkFlow.com SETTLEMENT AGREEMENT ­ FINAL RECEIPT AND RELEASE OF LIABILITY K-WC Form D (Rev. 6-12) Kansas Department of Labor Page 2 of 3 1. Employer's name____________________________________________________________________________________________________________ Address: Street______________________________________________ City________________________State_____________ZIP_____________ 2. Insurance carrier___________________________________________________________ Phone _________________________________ (Ext.)____________________ Address________________________________________________________________________________ Ins. Co. File No.____________________ 3. Injured worker___________________________________________________________ Social Security number_______________________________ Address: Street_________________________________________________ City________________________ State_____________ ZIP_____________ 4. Nature of injury for which this claim for compensation is made________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ 5. 6. 7. Date of injury____________________________________________ Last day employee worked_________________________________ Date employee was able to return to work ______________________________________________________ Compensation paid on the following basis: 12. _______weeks ______days temporary total disability ............................................ $ ________________ 13. _______weeks ______days _______% temporary partial disability @_______________________ per week ................. $ ________________ 14. _______weeks permanent partial disability for: Percent of amputation to _____________________ _________________________________________ _______% loss of use of _____________________ $ ________________ TOTAL COMPENSATION ................................................ $ ________________ 15. Hospital expense ....................................................... $ ________________ 16. Medical expense ....................................................... $ ________________ 17. Other (specify)_____________________________ $ ________________ Total Medical ............................................................. $ ________________ 8. 9. Date employee returned to work____________________________ If employee worked between date of injury and last date of disability, give dates_____________________________________________ ______________________________________________________ 10. Average weekly wage $___________________________________ 11. Weekly compensation rate $________________________________ NOTE: No compromise settlements shall be made on a final receipt and release of liability. 18. Is this a Release and Receipt for payments made on award of Director?_____________________________________________
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