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Lump Sum Settlement Form. This is a Maine form and can be use in Workers Compensation.
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Tags: Lump Sum Settlement, WCB-10, Maine Workers Compensation,
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Calendar No.
LUMP SUM SETTLEMENT
STATE OF MAINE
:
WORKERS'Plaintiff(s)
COMPENSATION BOARD
JUDICIAL
STATION 27, AUGUSTA, MAINE 04333-0027
-against-
SUBPOENA
:
1. INSURER FILE NUMBER:
6. SOCIAL SECURITY NUMBER
2. EMPLOYER NAME:
7. WCB FILE NUMBER:
8. EMPLOYEE LAST NAME:
:
9. FIRST NAME:
10. M.I.:
:
3. EMPLOYER MAILING ADDRESS AND PHONE NUMBER:
11. ADDRESS-NUMBER AND STREET:
Defendant(s)
:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12.. CITY: . . . . . . . . . . . . . . . 13. STATE:
. ...
4. INSURER NAME:
5. INSURER MAILING ADDRESS:
16. DATE OF INJURY:
14. ZIP:
15. HOME PHONE:
17. DESCRIPTION OF INJURY:
THE PEOPLE OF THE STATE OF NEW YORK
18.
TYPE OF SETTLEMENT:
TO
STRUCTURED SETTLEMENT
(ATTACH DOCUMENTATION)
19. PERMANENT IMPAIRMENT RATING
GREETINGS:
LUMP SUM SETTLEMENT
TOTAL VALUE OF SETTLEMENT $
%
AMOUNT PAID
$
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
21. PREPARER NAME AND TITLE (TYPE OR PRINT):
22. TELEPHONE NUMBER:
23.
in room
, on the
day of
, 20
, at
o'clock in the
noon,DATE: at any recessed
and
or adjourned date, to testify and give evidence as a witness in this action on the part of the
20. COMMENTS:
RELEASE
24.
EMPLOYEE/DEPENDENT:
I AM THE PERSON ENTITLED TO WORKERS' COMPENSATION BENEFITS ON ACCOUNT OF THIS INJURY OR DEATH.
Your THIS WORKSHEET with this subpoena is punishable as a contempt of court and will make you
I HAVE READfailure to comply AND ALL ATTACHMENTS. WHEN I RECEIVE THE AMOUNT SHOWN ABOVE AND THIS liable to
the party on whose behalf this subpoena wasOFFICER,for a maximumEMPLOYER AND INSURER NAMED ABOVE
SETTLEMENT IS APPROVED BY THE HEARING issued I RELEASE THE penalty of $50 and all damages sustained as a
FROM ALL failure to comply.
result of your FURTHER LIABILITY FOR THIS INJURY. I CONCENT TO THE SETTLEMENT.
EMPLOYEE/DEPENDENT SIGNATURE
Witness, Honorable
Court in
County,
day of
EMPLOYER/INSURER:
ATTORNEY SIGNATURE
DATE
, one of the Justices of the
, 20
THE EMPLOYER CONSENTS TO THE SETTLEMENT:
YES
NO
THE INSURER CONSENTS TO THE SETTLEMENT:
YES
SIGNATURE
DATE
NO
SIGNATURE
DATE
(Attorney must sign above and type name below)
DECISION
25.
THE REQUESTED SETTLEMENT (IS/IS NOT) APPROVED. THE EMPLOYER/INSURER IS ORDERED TO PAY
CIRCLE ONE
THE EMPLOYEE/DEPENDENT THE SUM OF $ ______________________________ IN Afor
Attorney(s) LUMP SUM
SETTLEMENT ACCORDING TO THE WORKERS' COMPENSATION ACT. THE EMPLOYER/INSURER IS
ORDERED TO PAY ALL OUTSTANDING COMPENSATION OBLIGATIONS INCURRED PRIOR TO THIS
SETTLEMENT BY THE EMPLOYEE/DEPENDENT. THEEMPLOYER/INSURER IS ORDERED TO PAY THE
ATTORNEY OF THE EMPLOYEE/DEPENDENT A FEE OF $ ______________________________________
Office and P.O. Address
ALL PENDING PETITIONS BASED ON THIS CLAIM ARE HEREBY DISMISSED.
Telephone No.:
DATE
Facsimile No.:
E-Mail Address:
THIS DOCUMENT MAY BE PRODUCED IN ALTERNATIVE FORMATS SUCH AS BRAILLE, LARGE PRINT AND AUDIOTAPE.
WCB 10 (3/98)
Mobile Tel. No.:
HEARING OFFICER SIGNATURE
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