WORKERS’ COMPENSffATION COMMISSION 10 EAST BALTIMORE STREET, BALTIMORE, MD 21202-1641 410-864-5100 ● Email: info@wcc.state.md.us ● Web: http://www.wcc.state.md.us SETTLEMENT WORKSHEET Claim Number: Claimant: Employer: Insurer: THIS WORKSHEET to be made part of proposed Agreement of Final Compromise and Settlement: WHEREAS the undersigned, Claimant or Claimant’s attorney avers as follows: 1. Is the claim contested as to compensability and/or causation? Yes No 2. Is further medical treatment for the injury recommended? Yes No Yes No 3. Is there any potential S. I. F. liability in this case? Yes No 4. Is the Claimant working? Yes No 5. Is the claimant currently receiving: a) Social Security Disability Benefits? Yes No Yes No 6. Is a third party claim involved in this case? -IF YES, attach required document per Rule .19B Yes No 7. Is the claim on appeal? Yes No 8. Is there a hearing pending on this claim? -IF YES, When? Yes No -IF YES, does the Claimant have health care coverage for the recommended treatment? b) Medicare Benefits? 9. Are the proceeds of this settlement to be payable 10. All pertinent medical reports are attached OR weekly or in a lump sum? There are no medicals in this case. 11. Comments: Signature of Claimant Signature of Claimant’s Attorney Claimant’s Attorney Name: Attach only relevant Medical Information Street Suite, Etc. City, State, Zip Code Telephone Number: WCC Form H-07 (Rev 01/06) CLICK HERE TO CLEAR THE FORM