SETTLEMENT EVALUATION Employee's Name SIB Claim # SS# Medical History Pre -existing Subsequent Injury **************************************************************************** Comp Rate INDEMNITY: Pre Accident Av Wk Wg $ X $ Post Accident Wages $ $ Pre Acc. monthly wages Post Acc. monthly wages $ X .6667 (66 2/3%) SEB Monthly Exposure SEB Weekly Exposure Total owed under LA Law Total Indemnity paid to date Remaining Weeks Total Indemnity SEB Exposure Discounted (8% W. C. Book) $ $ $ $ __________ Weeks Weeks __________ Weeks ÷ 4.3 X 4.3 (SEB based on 4.3 weeks/mo) Monthly Salary $ hrs / wk = X 4.3 = Average Weekly Wage Occupation Part of Body Age D/A Post Monthly Salary MEDICAL: Total Exposure Discounted 8% TOTAL FUTURE EXPOSURE DISCOUNTED VALUE (8%) SETTLEMENT REQUESTED $ $ $ $ $ SIB AUTHORIZED FULL & FINAL SETTLEMENT IN THE AMOUNT OF NOTES: APPROVED BY: PROGRAM COMPLIANCE OFFICER SIB DIRECTOR DATE DATE American LegalNet, Inc. www.USCourtForms.com