Kansas > Workers Compensation
Work Sheet For Settlements Injury Case K-WC 12 - Kansas
| Work Sheet For Settlements Injury 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 K-WC 12 (Rev. 6-12) WORK SHEET FOR SETTLEMENTS: INJURY CASE Docket No. Claimant Respondent Insurance Carrier Date of hearing Appearances: Claimant appeared by Heard by Social Security number Place of hearing Respondent (and insurance company) appeared by Workers' Compensation Fund appeared by Date of accident Average weekly wage $ Medical evidence to be admitted Place of accident Compensation paid $ Medical and hospital expenses Basis of Settlement: (1) Compromise $ on a strict compromise of the following issues: (2) Scheduled Injuries $ for amputation of (scheduled member) (scheduled member) , or (as per medical report). % permanent partial loss of use of (3) General Bodily Disability $ for % permanent partial general bodily disability (as per medical report). 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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