MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS 3315 West Truman Blvd., P.O. Box 58 Jefferson City, MO 65102-0058 1. INJURY NUMBER STIPULATION FOR COMPROMISE SETTLEMENT EMPLOYEE EMPLOYER + SOCIAL SECURITY NUMBER TELEPHONE NUMBER XXX-XXINSURER It is hereby stipulated and agreed by and between the parties hereto: 1. That on or about , the above-named EMPLOYEE, while in the employment of the abovenamed employer, sustained an accidental injury/occupational disease arising out of and in employment and that an accidental injury/occupational disease resulted in injury to the EMPLOYEE. 2. Compensation Law. 3. That the weekly compensation rate is $ for temporary benefits and $ for permanent partial disability. 4. That employer and insurer have paid medical expenses in the amount of . . . . . . . . . . . . . . . . . . . . $ 5. That employer and insurer have paid temporary disability for weeks in the amount of $ 6. That there are dispute(s) between the parties to 7. That because of the dispute(s) it is agreed by the parties to enter into a compromise lump sum settlement under Section 287.390, RSMo, as amended for the payment of a lump sum of . . . . . . . $ This settlement is based upon approximate disability of % of and that weeks of disfigurement is included. 8. That the SECOND INJURY FUND is making a payment of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 9. That the preexisting disability and percentage are 10. That the EMPLOYER/INSURER shall be responsible for payment or satisfaction of all bills and charges for medical treatment authorized by EMPLOYER or INSURER pertaining to this accident/disease. ADDITIONAL COMMENTS: THE EMPLOYEE UNDERSTANDS: by entering into this settlement, except as provided by Section 287.140.8, RSMo, the EMPLOYEE is further compensation or esult in EMPLOYEE receiving more money or less money than is provided by this settlement; that EMPLOYER/INSURER and/or SECOND INJURY FUND is/are released from all liability for this accident/disease upon approval by the Administrative Law Judge. EMPLOYEE asks the % of any amounts recovered by this settlement. The EMPLOYEE elects to receive payment in one lump sum. The PARTIES by their signatures below agree to the settlement, and the PARTIES request and recommend that this settlement be approved and that the settlement is in accordance with the rights of the parties. The EMPLOYER and EMPLOYEE indicate that the settlement is not the result of undue influence or fraud; the EMPLOYEE fully understands his/her rights and benefits; and the EMPLOYEE voluntarily agrees to accept the terms of the agreement. By initialing the following box, EMPLOYEE indicates full awareness of the consequences of this settlement as set out above and that EMPLOYEE DID NOT APPEAR IN PERSON BECAUSE OF HARDSHIP OR OTHER EXTENUATING CIRCUMSTANCES. By initialing the following box, EMPLOYEE indicates full awareness of the consequences of this settlement as set out above and that EMPLOYEE personally appeared. Employee Signature (Notary is required only if employee is not represented and does not appear.) Subscribed and sworn to before me this _______________ day of ____________________________. My commission expires: Tax I.D. Number Bar Number Telephone Number NOTARY PUBLIC: ____________________________________________________ ATTORNEY FOR EMPLOYEE (Signature) Bar Number (Print Name) Telephone Number ATTORNEY FOR SIF (Print Name) (Signature) ATTORNEY FOR EMPLOYER/INSURER (Print Name) (Signature) Bar Number Telephone Number FEE/LIEN: Settlement and Attorney Fees/Lien Attorney Fee/Lien in favor of ADMINISTRATIVE LAW JUDGE (Signature) (Print Name) for $ DATE + APPROVED BY: WC-G-11 WC-G-11 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com
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