W.C.C. # of pending cases: __________________________ __________________________ State of Rhode Island and Providence Plantations Workers’ Compensation Court Providence, SC. V. W.C. C. # Attorney Worksheet for Lump Sum or Structured-Type Settlements 1. 2. 3. 4. 5. 6. Petitioner’s Name Soc. Sec. # XXX-XXlast 4 digits only Date of Injury Average Weekly Wage $ Weekly Compensation Rate $ Proposed Settlement $ a) Has the employee, now or in the past, ever been a Medicare beneficiary or applied for Medicare benefits? Yes______ No ______ b) Has the employee ever collected or been qualified to receive age related Social Security benefits? Yes______ No______ 7. Has the employee collected Workers’ Compensation benefits for more than 6 months? Yes______ No______ The undersigned attorneys certify that the following documents are included in this settlement package. 1. Stipulation Assigning Petition for Settlement. 2. Original and copy of the proposed order approving petition as well as an original and copy of the proposed final decree. 3. Legible copies of ALL agreements or decrees establishing liability and periods of disability as well as any and all agreements and decrees for specific compensation. 4. Affidavit from employer’s attorney or statement from employer regarding settlement. a.) Attach a copy of the letter from the attorney and or insurer advising employer of details of proposed settlement and the right to be heard. b.) Attach a copy of the letter from the attorney and or insurer advising employer of any potential effect of proposed settlement on their workers’ compensation premium. 5. Copies of all Impartial Medical Examinations. 6. Statement of Treating Physician. If the employee is still treating: Statement must be dated within 30 days of the date of the filing of the petition. If the employee has stopped treating: A medical report from the physician with whom the employee last treated together with a statement of counsel that to the best of their knowledge this is the last medical report. 7. Life Expectancy Tables. 8. Affidavit of claimant regarding CMS: Medicare and Social Security if applicable 9. A list of all treating medical providers including any and all outstanding balances due and owing. Signature of Employee’s Attorney Signature of Employer’s Attorney Address and Phone Number of Employee’s Attorney Address and Phone Number of Employer’s Attorney Bar Number of Employee’s Attorney Bar Number of Employer’s Attorney Rev. 02/08 American LegalNet, Inc. www.FormsWorkflow.com