COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. DIVISION OF WORKERS’ COMPENSATION SETTLEMENT CHECKLIST AND ROUTING SHEET : Index No. Customer Service 303.318.8700 Claimant’s name: ______________________________________________________________ Social Security Number ____________________________ : Calendar No. List all workers’ compensation (WC#) numbers included in this settlement: WC#: _______________________DOI______________ -againstWC#: _______________________DOI______________ WC#: _______________________DOI______________ WC#: _______________________DOI______________ Claimant’s Attorney ________________________________ Reg. # _______________________ Type of settlement (check one): Full and Final Settlement (F) Partial Settlement (P) Third Party . . . . . . . . . . . . . . . . .(T) . . . . . . . . . (Subrogation) Settlement . . Structured Settlement: Limited Period of Time (S) Structured Settlement: Lifetime (L) Total amount of settlement award: (Include lump sum plus present value of any structured settlement) Defendant(s) Carrier Portion: $__________________________ SIF Portion: $__________________________ $_______________________________ Major Med Portion $__________________________ : JUDICIAL SUBPOENA Plaintiff(s) Respondent’s Attorney _____________________________ Reg. # _______________________ Other Attorney ____________________________________ Reg. # _______________________ : Other Attorney ____________________________________ Reg. # _______________________ : Other Attorney ____________________________________ Reg. # _______________________ : .......................... Verify the following by checking the boxes provided: 1. THE PEOPLE OF THE STATE OF NEW YORK Claimant is represented by an attorney . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Workers’ compensation numbers are correct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. TO Order and settlement document contain caption with WC number(s), claimant’s name, employer’s name and insurance carrier’s name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Settlement document has original signatures of all parties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Claimant’s signature on settlement document is notarized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 GREETINGS: Waiver of right to reopen is properly conditioned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. Documents include a standard order containing language required by the Division . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 9. 10. WE COMMAND YOU, that all on the order as excuses settlement .. . . . . . . . . and Date claimant signed the settlement document is entered business and the date of being laid. aside,. you . . . For DOWC use only Y N _____________ Y N _____________ Y Y Y Y Y Y N _____________ N _____________ N _____________ N _____________ N _____________ N _____________ each of you attend before , the Honorableprovides that the claimant has personally reviewed the stipulation with an attorney and waives at the Court Y N _____________ Settlement document located Administrative Law Judge . . . . . . . . . . . . . . . . . . . . . . . . Countypersonal appearance before the Director or at of the right to a in room , on the day of , 20 , at o'clock in the noon, and at any recessed All hearings before the Office of Administrative Courts and appealsabefore ICAP, Court of Appeals and Supreme Court have been vacated or or adjourned date, to testify and give evidence as witness in this action on the part of the dismissed for the workers’ compensation cases listed in this settlement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. All mediation, prehearing and settlement conferences before the Division of Workers’ Compensation have been canceled . . . . . . . . . . . . . . . . . I certify that I reviewed the attached settlement document and order, and that is punishableof the above information. Your failure to comply with this subpoena they contain all as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a __________________________________________ _____________ ________________________________________________________________ Signature Print Name result of your failure to comply. Date Representative for: Claimant Respondent Resubmitted (if initially rejected) Witness, Honorable __________________________________________ _____________ Signature Court in Date County, day of Instructions for document return: Will pick up at Customer Service Contact person for information: ________________________________ ____________________________ Name Phone number ________________________________________________________________ , one of the Justices of the Print Name Representative for: Claimant Respondent , 20 Please mail (Division will mail only if sufficient copies, with addressed, stamped envelopes for all parties are attached) Contact person for document pickup: (Attorney must sign above and type name below) ________________________________________ __________________ Name Phone number This form must be completed and submitted with the settlement document and order. Include a mailing certificate if the order is to be mailed. Submit the original settlement document and copies for all parties listed on the mailing certificate. Failure to correctly complete and submit all documents may result in rejection or return Attorney(s) for of the settlement. Settlement documents for claimants not represented by an attorney must be submitted directly to the Office of Administrative Courts. Do not complete this form if the claimant is unrepresented. Division of Workers’ Compensation Use Only: Approved Date: __________________________ By:_________________________________________________________________ Rejected (see # ____ above) Date: __________________________ By:_________________________________________________________________ Office and P.O. Address Person picking up documents: _____________________________________________________ _________________________________________________ Print Name Signature On behalf of: ____________________________________________________________________________ Date: ________________________________ Telephone No.: Mail or deliver all documents to: Division of Workers’ Compensation, Customer Service Facsimile No.: 633 17th Street, Suite 400, Denver, CO 80202-3660 E-Mail Address: Mobile Tel. No.: WC105 Rev 06/05 American LegalNet, Inc. www.USCourtForms.com