Montana > Workers Compensation
Petition For Settlement - Injury Or Occupational Disease - Montana
| Petition For Settlement - Injury Or Occupational Disease Form. This is a Montana form and can be used in Workers Compensation . |
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Department Settlement Requirements from Adjusters and/or Attorneys Settlement of Permanent Partial Disability benefits on an accepted claim with medical and hospital benefits reserved: "Petition for Settlement Injury / Occupational Disease" (this petition is also used when there is a dispute regarding PTD vs. PPD. Add language to this effect. Social Security offset language can also be added) Claimant name Insurer name Employer name Claim number Agency Claim Number Adjusters have access to this number on the EPC system Date of injury Dollar amount of settlement Present value calculation, if applied - Language regarding the application of present value will need to be on the petition not just the Recap Sheet Credit taken for previously paid PPD Language will need to be on the petition not just the Recap Sheet Special Provisions, if any Original claimant signature and address Original witness signature Date signed Original Authorized Representative Signature Recap Sheet Section 1 Claimant name, date of injury and claim number For dates of injury post 7/1/91 complete Section 4 For all dates of injury complete Section 5 Claimant and Authorized Representative's signature in Section 6 Attorney name and dollar amount of fees in Section 7 American LegalNet, Inc. www.FormsWorkFlow.com BEFORE THE DEPARTMENT OF LABOR & INDUSTRY Employment Relations Division Claimant PETITION FOR SETTLEMENT INJURY/OCCUPATIONAL DISEASE MEDICAL BENEFITS RESERVED Insurer's Claim #: Employer ACN Claim#: Insurer The claimant suffered an injury arising from a work-related accident or occupational disease occurring on . The insurer accepted liability for the claim. The claimant and insurer have agreed to settle all compensation payments due the claimant under the Workers' Compensation/Occupational Disease Acts. The claimant shall accept the lump sum of: ($ ) paid by the Insurer. The settlement amount shall be paid in a lump sum in addition to all sums previously paid by the insurer, unless otherwise indicated in the special provisions section of the Petition.* The claimant and insurer petition the Department of Labor & Industry for approval of this settlement allowing the claim(s) to be fully and finally closed. Further medical and hospital benefits are reserved by the claimant. These benefits terminate when they are not used for a period of 60 consecutive months. The claimant, in signing and submitting this Petition to the Department of Labor & Industry, further understands that if this Petition is approved, this insurer is forever released from payment of compensation under the Workers' Compensation and Occupational Disease Acts for the claim(s) specified above. The claimant understands this Petition represents a settlement and, if approved, may not be reopened by the Department. *Special Provisions: Vocational Rehabilitation Provisions: ________________________ Claimant's Signature Claimant's Address: Street/PO Box: City: State: Zip Code: The ______________ Date Signed ________________________ Witness Signature concurs and joins in the Petition for Settlement. ______________________________ Insurer Authorized Representative __________ Date Order The Department of Labor & Industry hereby orders that the above settlement is approved. Dated the ___________ day of _________________, _________. ___________________________________________ Signature of Authorized Department Representative Revised 5/12/09 American LegalNet, Inc. www.FormsWorkFlow.com
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