W.C.C. # of pending cases: __________________________ __________________________ State of Rhode Island and Providence Plantations Providence, SC. Workers' Compensation Court V. W.C. C. # Worksheet for "Meds Open" Settlements Where Medical Payments Will Continue 1. Petitioner's Name 2. Date of Injury 3. Average Weekly Wage $ $ $ Soc. Sec. # XXX-XXlast 4 digits only 4. Weekly Compensation Rate 5. Proposed Settlement 6. 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. Petition for settlement and stipulation assigning petition for hearing. 2. 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. a.) If benefits or expenses have been paid for any "flow from" injuries, mutual agreements reflecting these conditions must be filed. 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. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com W.C. C. # 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: The medical report from the physician with whom the employee last treated together with an affidavit signed by the employee or her/ his attorney that she/he is no longer treating. 7. Current life expectancy tables setting forth the employees life expectancy. 8. 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 of Employee's Attorney Phone Number of Employee's Attorney Bar Number of Employee's Attorney Address of Employer's Attorney Phone Number of Employer's Attorney Bar Number of Employer's Attorney Revised 02/14 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com