State of California SETTLEMENT OF PROSPECTIVE VOCATIONAL REHABILITATION SERVICES [LC § 4646 (b)] SSN (Numbers Only) Case Number Date of Birth: MM/DD/YYYY Claim Number (Choose only one) a specific injury on MM/DD/YYYY a cumulative trauma injury which began on (START DATE: MM/DD/YYYY) and ended on (END DATE: MM/DD/YYYY) Employee (All information in this section must be completed) MI First Name Last Name Street Address /PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone Employee's Attorney (All information in this section must be completed) First Name MI Last Name Firm Name Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone (Voc. Rehab.) §10133.22 (Page 1) - Rev 11/2008 RU122 Claims Administrator Information (if known and if applicable) Name (Please leave blank spaces between numbers, names or words) Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code State Zip Code Employer (All information in this section must be completed) Employer Name (Please leave blank spaces between numbers, names or words) Street Address/PO Box (Please leave blank spaces between numbers, names or words) City Employer's Representative (If Applicable) First Name MI Last Name Firm Name Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone (Voc. Rehab.) §10133.22 (Page 2) - Rev 11/2008 RU122 Qualified Rehabilitation Representative (if applicable) First Name MI Last Name Firm Name Street Address/PO Box (Please leave blank spaces between numbers, names or words) City State Zip Code Phone In accordance with Labor Code section 4646 : 1. The parties to this agreement are the employee and the employer or claims administrator 2. All parties agree that any vocational rehabilitation benefits paid and accrued prior to the date this agreement has been signed are separate and distinct funds from the amount settled in this agreement. 3. The parties hereby agree to settle the employee's right to prospective Vocational Rehabilitation services with a one-time payment to the employee for the sum of $ , , less the sum of $ as reasonable attorney's fee. The requested attorney's fee will be held in trust by the employer subject to approval and subsequent order by the Workers’ Compensation Appeals Board. 4. The employee's attorney has fully disclosed and explained to the employee the nature and quality of the rights and privileges being waived and settled by the parties. The employee has knowingly and voluntarily agreed to relinquish his or her rehabilitation rights. 5. The employee understands and agrees that the settlement is to be applied to his/her self directed vocational rehabilitation, such as direct placement, training, self-employment. The Rehabilitation Unit shall approve or disapprove the settlement agreement of vocational rehabilitation. If disapproval is not made within ten (10) days of receipt of a fully executed agreement, the agreement shall be deemed approved. This Agreement is Final. Any aggrieved party must file an appeal with the Workers' Compensation Appeals Board within twenty (20) days from the date this Agreement is approved, deemed approved or disapproved. (Voc. Rehab.) §10133.22 (Page 3) - Rev 11/2008 RU122 If Vocational Rehabilitation Services were commenced: Summary of Services Provided Number of weeks of VRMA Total Amount of VRMA Paid $ Total Amount of PD Supplement: $ Amount Paid QRR for DOI’s on or after 1/1/03 Phase A: $ Phase B: $ Total costs of QRR services $ QRR Name Total other costs of rehabilitation services: $ Amount withheld for Employee’s Representative, if any: $ If plan developed, plan type: Completed by: Date: MM/DD/YYYY Employee's signature: Date: _______________ MM/DD/YYYY Employee's Attorney's signature: Date: _______________ MM/DD/YYYY Employer's Representative: Date: _______________ MM/DD/YYYY Qualified Interpreter's signature: (If Needed) Date: _______________ MM/DD/YYYY Interpreter's License Number: (Voc. Rehab.) §10133.22 (Page 4) - Rev 11/2008 RU122 Rehabilitation Unit California Division of Workers' Compensation Form RU-122 SETTLEMENT OF PROSPECTIVE VOCATIONAL REHABILITATION SERVICES Purpose : To record the agreement between the employee and the employer to settle prospective vocational rehabilitation services for injuries on or after 1/1/03. Submitted by : Any party. When Submitted : When the parties have agreed to settle prospective vocational rehabilitation services. Where Submitted : To the applicable Rehabilitation Unit district office. The Rehabilitation Unit’s venue is the same as the WCAB. If no WCAB case exists, file with a Rehabilitation Unit within the county where the injured employee resides. Form Completion : Identifying data completed by claims administratorSignature of employee, employee's representative and claims administrator. Accompanying documents : None. Rehabilitation Unit Action : The Rehabilitation Unit shall either issue a determination based on the record, request additional information , or set the matter for formal conference. Copy : All parties. (Voc. Rehab.) §10133.22 (Page 5) - Rev 11/2008 RU122