Montana > Workers Compensation
Petition For Settlement - Permanent Total Disability - Montana
| Petition For Settlement - Permanent Total Disability 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 Total Disability benefits on an accepted claim with medical and hospital benefits reserved: (Used Only when all parties agree the claimant is PTD) "Petition for Settlement Injury / OD (Permanent Total Disability)" 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 Special Provisions, if any Lump Sum Justification, i.e. pre and post settlement income and expenses, a description of what the lump sum will be used for, demonstrating how the claimant will be financially sound with a lump sum as opposed to biweekly payments. (Relates to the necessities of life, an accumulation of debt incurred prior to the injury or a self-employment venture that is considered feasible under criteria set forth by the department) Include copies of debt documentation, if applicable 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 (Permanent Total Disability) INJURY/OCCUPATIONAL DISEASE Insurer's Claim #: Employer ACN #: 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 insurer shall pay to the claimant the sum of: ($ ). The settlement amount shall be paid in a lump sum in addition to all sums previously paid by the insurer, unless otherwise indicated in this Petition.* The basis for settlement of this claim is that the claimant is permanently and totally disabled as defined in the Acts. This settlement is based on the claimant's total disability benefit rate after the rate has been reduced as a result of the offset taken against the claimant's social security disability benefits, if any. The claimant and insurer petition the Department of Labor & Industry for approval of this settlement allowing the claim 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: ____________ Date Signed ___________________________ Witness Signature Zip Code: The 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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