Petition For Settlement (Disputed Initial Compensability)

Department Settlement Requirements from Adjusters and/or Attorneys Settlement of indemnity, medical and hospital benefits on a denied claim: Denial letter "Petition for Settlement Disputed Initial Compensability" (Recap Sheet not required) 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 Original claimant signature & address Original witness signature Date signed Original Authorized Representative Signature Attorney fees, if applicable The Department should already have a copy of the denial letter (not just the 608 or 615 letter) but you may want to include a copy. American LegalNet, Inc. www.FormsWorkFlow.com BEFORE THE DEPARTMENT OF LABOR & INDUSTRY Employment Relations Division Does not require Recap Sheet Claimant PETITION FOR SETTLEMENT DISPUTED INITIAL COMPENSABILITY Insurer's Claim#: Employer ACN #: Insurer The claimant reported an injury arising from a work-related accident or occupational disease occurring on . The insurer has disputed liability for the claim. The controversy concerning the insurer's disputed liability and denial of the claim has been resolved by an agreement between the claimant and the insurer, whereby the claimant agrees to accept the lump sum of: ($ ) paid by the insurer. This 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 this Petition.* The claimant understands, that by entering into a settlement and signing and submitting this Petition to the Department of Labor & Industry, that if this Petition is approved, the insurer is forever released from payment of compensation, medical, and/or vocational rehabilitation benefits under the Workers' Compensation and Occupational Disease Acts for injuries or diseases claimed to have been suffered as indicated above. The claimant and insurer petition the Department of Labor & Industry for approval of this settlement. If this settlement is approved, the claim will be forever closed and may not be reopened by the Department. Further medical, hospital, vocational rehabilitation and all indemnity benefits are expressly closed. *Special 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. Claimant's Attorney:___________________ Fee: $__________________ (Do not include costs) ______________________________ 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 Form DLI/ERD PS-DIC-LGL Revised 7/12/2011 American LegalNet, Inc. www.FormsWorkFlow.com