Lump Sum Settlement {WCB-10}

LUMP SUM SETTLEMENT STATE OF MAINE WORKERS' COMPENSATION BOARD 27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027 1. INSURER FILE NUMBER: 2. EMPLOYER NAME: 3. EMPLOYER MAILING ADDRESS AND PHONE NUMBER: 4. INSURER NAME: 5. INSURER MAILING ADDRESS: 6. SOCIAL SECURITY NUMBER (last 4 digits): 8. EMPLOYEE LAST NAME: 11. ADDRESS-NUMBER AND STREET: 12. CITY: 16. DATE OF INJURY: 13. STATE: 14. ZIP: 17. DESCRIPTION OF INJURY: 15. HOME PHONE: 7. WCB FILE NUMBER: 9. FIRST NAME: 10. M.I.: XXX-XX- 18. TYPE OF SETTLEMENT: STRUCTURED SETTLEMENT (ATTACH DOCUMENTATION) LUMP SUM SETTLEMENT TOTAL VALUE OF SETTLEMENT $_________________ AMOUNT PAID $_____________________________ 19. PERMANENT IMPAIRMENT RATING ___________________ % SOURCE OF RATING _______________________________ DATE OF RATING ______________________________ 20. EXPECTED FUTURE MEDICAL COSTS RELATED TO THE INJURY: $ ________________________ 21. COMMENTS: 22. EMPLOYER/INSURER REPRESENTATIVE (TYPE OR PRINT): 23. EMPLOYEE REPRESENTATIVE (TYPE OR PRINT): RELEASE 24. EMPLOYEE/DEPENDENT: I AM THE PERSON ENTITLED TO WORKERS' COMPENSATION BENEFITS ON ACCOUNT OF THIS INJURY OR DEATH. I HAVE READ THIS FORM AND ALL ATTACHMENTS. I CONSENT TO THE SETTLEMENT. WHEN THE SETTLEMENT IS APPROVED BY THE ADMINISTRATIVE LAW JUDGE, I RELEASE THE EMPLOYER AND INSURER NAMED ABOVE FROM ALL FURTHER LIABILITY FOR THIS INJURY, EXCEPT AS OTHERWISE APPROVED BY THE BOARD. _________________________________ EMPLOYEE/DEPENDENT SIGNATURE ____________ DATE ____________________________________ EMPLOYEE REPRESENTAIVE SIGNATURE _____________ DATE 25. EMPLOYER/INSURER: THE EMPLOYER CONSENTS TO THE SETTLEMENT: THE INSURER CONSENTS TO THE SETTLEMENT: YES YES NO NO ______________________ SIGNATURE ________________ DATE ______________________ SIGNATURE ________________ DATE 26. THE REQUESTED SETTLEMENT (IS/IS NOT) APPROVED. THE EMPLOYER/INSURER IS ORDERED TO PAY THE EMPLOYEE/DEPENDENT THE SETTLEMENT AMOUNT OF $ ______________________________ AND ALL OUTSTANDING COMPENSATION OBLIGATIONS INCURRED PRIOR TO THE SETTLEMENT. PAYMENT MUST BE MADE WITHIN 10 DAYS PURSUANT TO 39-A M.R.S.A. 324(1). THE EMPLOYER/INSURER IS ORDERED TO PAY THE EMPLOYEE/DEPENDENT'S ATTORNEY A FEE OF $ ____________________. ALL PENDING PETITIONS BASED ON THIS CLAIM ARE HEREBY DISMISSED. __________________________________________ ADMINISTRATIVE LAW JUDGE SIGNATURE _______________________ DATE DECISION The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this form, contact the ADA Coordinator at the Maine Workers' Compensation Board. Telephone: 1-888-801-9087 or TTY Maine Relay 711. WCB-10 (eff. 1/1/13, rev. 10/15/15) American LegalNet, Inc. www.FormsWorkFlow.com