Settlement Advance Recap Sheet

Revised 10/07/1 1 DLI - ERD - WCC005 EMPLOYMENT RELATIONS DIVISION SETTLEMENT/ADVANCE RECAP SHEET Please complete the applicable sections PETITION TITLE: 1. CLAIMANT: ACN# Claim#: D/A or OD: (Include a ll Dates) INSURER PRIMARY CLAIM (S) #: ADDITIONAL CLAIMS 2. DATES OF INJURY PRE 7/1/87 Pre Lump Sum: Post Lump Sum: Income: $ Income: $ Expenses: $ Expenses: $ Differences: $ 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: % Education: % Wage Loss: % Rest rictions: % Impairment: % Total Award: % $ Has the claimant been released to job of injury? Yes No Is the claimant currently working? ( If yes, current wage) Yes No 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 retu rn to work ): Impairment Rating % Paid: Yes No Settlement/Advance Amount: $ Settlement/Advance Rationale & Calculations ( includ e present value calculations if applicable ): 5. (or authorized representative) (or authorized representative) TO THE BEST OF MY KNOWLEDGE THE ABOVE INFORMATION IS TRUE AND CORRECT 6. Fee: $ (Do not include costs) American LegalNet, Inc. www.FormsWorkFlow.com Revised 10/07/1 1 DLI - ERD - WCC005 7. Reviewed by: Date: (ERD Examiner) Questions concerning this form should be addressed to: Emp loyment Relations Division Claims Assistance Bureau PO Box 8011 Helena MT 59604 - 8011 Phone (406) 444 - 6543 American LegalNet, Inc. www.FormsWorkFlow.com