KANSAS DEPARTMENT OF LABOR www.dol.ks.gov K-WC 13 (Rev. 5-14) WORKSHEET FOR SETTLEMENTS: DEATH CASE Heard by: Docket No.: Claimant(s): Respondent: Date of hearing: Appearances: Claimant(s) appeared by: Insurance Carrier: Place of hearing: Respondent (and insurance company) appeared by: Workers' Compensation Fund appeared by: Date of accident: Place of accident: Average weekly wage: $ Medical evidence to be admitted: Compensation paid: $ Date of death: Medical and hospital expenses: Exhibits: Death Certificate: Birth Certificates: Funeral expenses: Basis of Settlement: 1. Compromise $ on a strict compromise of the following issues: attached attached not applicable Marriage Certificates: attached not applicable not applicable Letters of Conservatorship: attached 2. $ $ Not to exceed $ per week to surviving spouse and per week to each of dependents DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone: (785) 296-4000 American LegalNet, Inc. www.FormsWorkFlow.com