Settlement Agreement and Application for Approval of Settlement Agreement for state-fund claims only Instructions · Youmustfilethisformwhenrequestingasettlement.Inaddition: o Ifyouareaninjuredworkerreceivingpermanenttotaldisability(PTD)benefits,aninjured workerwhoisrequestingconsiderationofPTDbenefitsoraclaimantcurrentlyreceiving deathbenefits,youmustcompleteandsubmitwiththissettlementapplication: ­ Medical History and Disclosure(C-242)formwithsupportingmedicaldocumentationand; Ifapplyingforfullsettlementthe: ­ PTD-Death Settlement Acknowledgment and Waiver(C-243)or; Ifapplyingforanindemnityonlysettlementthe: ­ Indemnity Only Settlement Acknowledgment and Waiver(C-245). o Ifyouareaninjuredworkerapplyingforanindemnityonlysettlement,youmustcomplete andsubmitwiththissettlementapplication: ­ Indemnity Only Settlement Acknowledgment and Waiver (C-245). · Youmustsubmitrequiredinformationlistedabovetoavoiddelaysinprocessingand/or disapprovaloftheapplication. · BWCmayrequestthataninjuredworkersubmittheC-242formwithsupportingmedical documentationforclaimsotherthanthoselistedabove. · Byfilingthisapplication,theclaimantandtheemployerunderstandBWCwillsuspendall unresolvedclaimissues,exceptissuesrelatedtotemporarytotalbenefits,PTDbenefitsand alternativedisputeresolutions,whichBWCwillcontinuetoprocess. · Ongoingcompensationandmedicalpaymentswillcontinueuntiltheeffectivedateofthe settlement. · Thisapplicationcanonlybeusedtosettleaclaim(s)withasingleemployer.Ifyouwishto settleclaimsthatareassignedtoadifferentemployer,youmustfileaseparateapplication. · UseaSelf-insured Joint Settlement Agreement and Release(SI-42)topursueasettlement withaself-insuringemployer. · Submitthisform,viafaxto1-866-336-8352,orsendittoyourlocalBWCcustomerservice office. BWC-1372(Rev.Nov.2,2016) C-240 American LegalNet, Inc. www.FormsWorkFlow.com Settlement Agreement and Application for Approval of Settlement Agreement for state-fund claims only Specialnoticetomedicarebeneficiaries Areyoureceiving,orhaveyouappliedforMedicarebenefitsorfiledanappealonadeniedapplication? Yes No Ifyes,Medicaredoesnotpaymedicalbillsforconditionscoveredbyyourworkers'compensationclaim.Ifa settlementofyourworkers'compensationclaimisreached,andthesettlementallocatescertainamountsfor futuremedicalexpenses,Medicaredoesnotpayforthoseservicesuntilmedicalexpensesrelatedtoyourworkers'compensationclaimequaltheamountofthelumpsumsettlementallocatedtofuturemedicalexpenses.For additionalinformation,pleasecalltheMedicarecoordinationofbenefitscontractorat800-999-1118. Claimantdemographicinformation Claimantname Address Emailaddress City State Dateofbirth ZIPcode Phonenumber Home Cell Claimantrepresentativedemographicinformation Claimantrepresentativename Emailaddress Faxnumber Phonenumber RepresentativeIDnumber Employerofrecorddemographicinformation Employername Emailaddress Risknumber Faxnumber Phonenumber Employerrepresentativedemographicinformation Employerrepresentativename Emailaddress Faxnumber Phonenumber RepresentativeIDnumber AllclaimsforwhichtheclaimantandabovenamedemployermakeapplicationtoBWCforapprovalofsettlement. Claimnumber Pleaseselecttypeofsettlementbeingrequested (selectonlyfullorpartial). Fullsettlement Fullsettlement Fullsettlement Fullsettlement Fullsettlement Fullsettlement Indemnityonlysettlement Indemnityonlysettlement Indemnityonlysettlement Indemnityonlysettlement Indemnityonlysettlement Indemnityonlysettlement Requestedsettlementamount Clearlysetforththecircumstancesbyreasonofwhichtheproposedsettlementisdeemeddesirable,describebriefly whyyouwanttosettleyourclaim(s).ThisinformationisREQUIREDpursuantOhioRevisedCode(ORC)4123.65. BWC-1372(Rev.Nov.2,2016) C-240 Page1of3 American LegalNet, Inc. www.FormsWorkFlow.com MedicalInformation Ifyouareaninjuredworker,areyoureceivingmedicaltreatmentatthistimeforanyoftheclaimslistedabove? Yes No Employmentstatusinformation Ifyouaretheinjuredworker,youarerequiredtoanswerthefollowingquestions: Areyoustillanemployeeoftheemployerlistedabove(theinjuryemployer)? Yes Areyouworking? Yes No No Ifyes,whatisyourpresentoccupation:_____________________________________________________________________ Nameoftheemployer:__________________________________________________________________________________ Whatareyourpresentwages?Perhour:____________________________Perweek____________________________ Ifno,areyouretired? Yes No Employer/attorneysignature(RequiredbyORC4123.65unlessanexceptiontotheemployer'ssignatureapplies) Instructions Pleasecheckoneofthefollowingboxesandsignbelow.Yoursignaturedoesnotwaivetheemployer'srightto withdrawconsenttothesettlementbyprovidingwrittennoticetotheemployeeandtheBWCadministratorwithin 30daysaftertheadministratorissuestheapprovalofthesettlementagreement. A.Theemployerissupportiveofandagreeabletoasettlementuptotheamountlistedonthefrontofthis application. B.TheemployerdoesnotagreewiththerequestedsettlementtermsbutwillparticipatewiththeBWCin thenegotiationprocess. C.Theemployerissupportiveofandagreeabletosettlementoftheclaimslistedonthefrontofthisapplication.However,theemployerwillnotparticipateinthesettlementnegotiationsandrequeststheBWCto negotiatethesettlementonbehalfoftheemployer. D.Theemployerisnotagreeabletosettlementoftheclaim(s)listedonthefrontofthisapplication. PursuanttoSection4123.65(A)oftheORC,theemployer'ssignatureisnotrequiredonthissettlement applicationif: · TheemployerisnolongerdoingbusinessinOhio,ortheemployerisstilldoingbusinessinOhio.However: o Theclaim(s)involvedinthesettlementapplicationisoutoftheemployer'sexperienceandthe claimantisnolongeremployedwiththeemployer; o TheemployerhasfailedtopaypremiumsasrequiredbySection4123.35oftheORC. Employer/attorneysignature(RequiredbyORC4123.65unlessanexceptiontotheemployer'ssignatureapplies) Iftheclaimtobesettledisastate-fundclaim,andtheemployerisnowself-insuring,BWCchargestheself-insuring employerdollarfordollarforanyportionofthesettlementattributedtopast,presentorfutureDisabledWorkers'Relief Fund(DWRF)liability.Bysigningthisagreement,thisself-insuringemployeracknowledgesitsobligationtoreimburse BWCfortheportionofthesettlementamountallocatedtoDWRFcostsoftheabove-referencedclaim(s).BWCwillbill theDWRFportionofthesettlementtotheself-insuringemployer,eveniftheclaimanthasnotyetbeendeterminedto bepermanentlyandtotallydisabledorcurrentlyeligibleforDWRFbenefits. Employersignature Employerattorneysignature Title AttorneyrepIDnumber Date Date BWC-1372(Rev.Nov.2,2016) C-240 American LegalNet, Inc. www.FormsWorkFlow.com Page2of3 Settleme