Kansas > Workers Compensation
Work Sheet For Settlements Death Case K-WC 13 - Kansas
| Work Sheet For Settlements Death Case 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 WORK SHEET FOR SETTLEMENTS: DEATH CASE K-WC 13 (Rev. 6-12) Docket No. Claimant(s) Heard by Respondent Date of hearing Appearances: Claimant(s) appeared by Insurance Carrier Place of hearing Respondent (and insurance company) appeared by Workers' Compensation Fund appeared by Date of accident Place of accident Average weekly wage $ Medical evidence to be admitted Compensation paid $ Date of death Medical and hospital expenses Exhibits: (1) Death Certificates (3) Birth Certificates Funeral expenses Basis of Settlement: (1) Compromise $ on a strict compromise of the following issues: (2) Marriage Certificates (4) Letters of Conservatorship (2) $ $ Not to exceed $ per week to surviving spouse and per week to each of dependents 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
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