Settlement Evaluation Permanent And Total

SETTLEMENT EVALUATION ­ PERMANENT & TOTAL SIB CLAIM # ____________ SS # ____________________ OCCUPATION ___________________________ BODY PART _____________________________ M F MEDICAL HISTORY PRE-EXISTING CONDITION: _________________________________________________________________ SUBSEQUENT INJURY: ______________________________________________________________________ COPY OF SIGNED ORDER FROM HEARING OFFICER DECLARING PERMANENT AND TOTAL. COMP RATE $____________ AGE ____________ AVERAGE WEEKLY WAGE $____________ LIFE EXPECTANCY (YEARS) ____________ INDEMNITY ANNUAL INCOME ($ ______ x 52 WEEKS) 8% DISCOUNTED UNDISCOUNTED VALUE $_______________ $_______________ $_______________ MEDICAL FUTURE SURGERY PHYSICAL THERAPY PHYSICAIN VISITS MEDICAL SUPPLIES OTHER TOTAL $_______________ $_______________ $_______________ $_______________ $_______________ $_______________ TOTAL AMOUNT (INDEMNITY PRESENT VALUE & MEDICAL) DISCOUNTED VALUE (8%) (INDEMNITY DISCOUNTED VALUE & MEDICAL) SETTLEMENT AMOUNT REQUESTED SIB AUTHORIZES FULL AND FINAL SETTLEMENT IN THE AMOUNT OF $_______________ $_______________ $_______________ $_______________ APPROVED BY: ________________________ PROGRAM COMPLIANCE OFFICER ___________DATE ________________________ SIB DIRECTOR ___________DATE American LegalNet, Inc. www.USCourtForms.com