Montana > Workers Compensation
Settlement-Advance Recap Sheet - Montana
| Settlement-Advance Recap Sheet Form. This is a Montana form and can be used in Workers Compensation . |
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Instructions: Recap Sheet Note: SECTIONS 1, 4, 5, & 6 ARE MANDATORY FOR ALL SETTLEMENTS 1. Claimant please spell correctly D/A or OD: List date of injury or if an occupational disease, date used by insurer as the onset date of the OD. List the dates of all claims being settled. Claim #: Use Insurer's claim number. List all claim #'s being settled. ACN#: Use Department's Agency Claim Number (ACN#). List all claims numbers being settled. 2. This section is to document financial sustainment per Administrative Rule of Montana 24.29.1201 ARM (for Dates of Accident from 4/15/85 to 6/30/87 see 1201-1204 ARM). Pre and post lump sum income should reflect the monthly income from all sources. Pre and post lump sum expenses should reflect the claimant's monthly expenses. For Permanent Total Petitions (all dates of injury) must show claimant would be better off with lump sum payment. If eliminating debts provide documentation per 24.29.1202 ARM. Social Security Offset: Provide the offset being applied to the Total Rate on Permanent Total Disability cases. 3. Section 39-71-703 MCA Entitlement 4. Settlement Information: This section is to be filled out for all dates of injury. Provide the date the claimant reaches MMI, or is provided an impairment rating or for Occupational Diseases is released to return to work Provide the dollar amount of the settlement or lump sum advance. Indicate on the petition if present value discount is being taken. Indicate on the petition any amount which will be deducted or added to the settlement . MMI: Provide the date the claimant reaches MMI, or the date the claimant is provided with an impairment rating or is released to return to work. Paid: Indicate if the impairment rating has been previously paid to the claimant. Rationale/Calculations: Provide a brief explanation of the reason for settlement and the calculations used to obtain the settlement amount. 5. Claimant/Witness Signature: Only the claimant can sign the petition. The claimant's signature must be witnessed and dated. The claimant or his/her authorized representative can sign the recap sheet. Insurer's Signature: The insurer or the representative of the insurer must sign both petition and recap sheet. 6. Attorney: If represented list claimant's attorney's name and the dollar amount of fees being charged on this settlement (do not include costs). 7. This section is to be completed by ERD staff. American LegalNet, Inc. www.FormsWorkFlow.com EMPLOYMENT RELATIONS DIVISION SETTLEMENT/ADVANCE RECAP SHEET Please complete the applicable sections PETITION TITLE: 1. CLAIMANT: ACN# Claim#: D/A or OD: (Include all Dates) INSURER CLAIM (S) #: (Include all Claim #'s) DATES OF INJURY PRE 7/1/87 2. Pre Lump Sum: Income: $ Expenses: $ Differences: $ Post Lump Sum: Income: $ Expenses: $ Differences: $ For dates of injury prior to April 15, 1985: See Instructions For dates of injury between April 15, 1985 and June 30, 1987: See Instructions 3. DATES OF INJURY POST 7/1/91 703 Benefits: PPD Rate: $ Age: Restrictions: % Education: % Impairment: % % Wage Loss: Total Award: % % Claimant's wage at the time of injury: $ Has the claimant been released to job of injury? Is the claimant currently working? (If yes, current wage) No Yes No Yes Current Wage: $ For Permanent Total Disability Settlements/Advances: See Instructions 4. SETTLEMENT/LUMP SUM ADVANCE INFORMATION (ALL DATES OF INJURY) Impairment Rating date or MMI date (All settlements require MMI date or date released to return to work): Impairment Rating % Paid: Yes No Settlement/Advance Amount: $ Settlement/Advance Rationale & Calculations (include present value calculations if applicable): 5. Insurer's Signature: _____________________________ Claimant's Signature: ___________________________________ (or authorized representative) (or authorized representative) TO THE BEST OF MY KNOWLEDGE THE ABOVE INFORMATION IS TRUE AND CORRECT 6. Claimant's Attorney: _____________________________ Fee: $_______________ (Do not include costs) 7. Reviewed by: ____________________________________ (ERD Examiner) Questions concerning this form should be addressed to: Employment Relations Division Claims Assistance Bureau PO Box 8011 Helena MT 59604-8011 Phone (406) 444-6539 Date: ___________________ Revised 5/12/09 American LegalNet, Inc. www.FormsWorkFlow.com
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