Maryland > Workers Compensation > Adjudication Claims
Settlement Worksheet HC-07 - Maryland
| Settlement Worksheet Form. This is a Maryland form and can be used in Adjudication Claims Workers Compensation . |
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WORKERS' COMPENSATION COMMISSION SETTLEMENT WORKSHEET Claimant: Claimant Atty.: Claimant's age: Employer: Insurer: years, months Claim No.: Atty. Telephone: This worksheet has been prepared by Claimant, or Claimant's attorney, for the purpose of securing the Commission's approval of the proposed Agreement of Final Compromise and Settlement. 1. 2. 3. 4. 5. Is the claim contested as to compensability and/or causation? Are further medical treatments recommended for the injury? Is there any potential SIF liability in the case? Is the Claimant working? Does this case involve a third party claim? If yes, attach document required by COMAR 14.09.01.19. 6. 7. Is the claim on appeal? Is a hearing on the claim pending? If yes, when? 8. Has Claimant applied for Social Security disability benefits? If yes, when (date)? 9. 10. 11. Is SSDI claim pending or on appeal? Date SSDI approved: Has Claimant applied for Medicare benefits? or N/A Yes No Yes No Yes No Yes Yes No No Yes Yes Yes Yes Yes No No No No No If yes, when (date)? 12. 13. 14. Is Medicare claim pending or on appeal? Date Medicare approved: or N/A Yes No Yes No Does Claimant have End State Renal Disease (ESRD)? CLICK HERE TO CLEAR THE FORM 10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us MD WCC Form H-07 6/27/2012 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com WORKERS' COMPENSATION COMMISSION SETTLEMENT WORKSHEET 15. 16. 17. Amount of Total Proposed Settlement: Total Amount of Indemnity paid to Claimant to date: Has a professional evaluator identified probable future Medicare covered expenses? If yes, attach professional evaluation. 18. Has proposed Medicare Set Aside been submitted to CMS? If yes, date submitted: 19. 20. 21. Is CMS approval of the MSA pending? Date CMS approved MSA: Is there a formal medical set aside allocation? If yes, state amount: $ If yes, is the MSA administered by a TPA or paid as an annuity, with no current or future reversionary interest to claimant? 22. Has some of the settlement been apportioned to future medicals? If yes, attach medical evaluation or opinion. Date of disablement by accidental injury or occupational disease: $ $ Yes No Yes No Yes or N/A Yes Yes Yes No No No No 23. 24. 25. Are medicals being left open? Comments: Yes No I hereby certify that the foregoing is true and accurate based on my personal knowledge, information and belief. Claimant Signature Attorney Signature 10 East Baltimore Street Baltimore, Maryland 21202-1641 410-864-5100 Email: info@wcc.state.md.us Web: http://www.wcc.state.md.us MD WCC Form H-07 6/27/2012 CLICK HERE TO CLEAR THE FORM Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
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