CASE FILE NO. _______________________ CARRIER FILE NO. ___________________ STATE OF DELAWARE OFFICE OF WORKERS’ COMPENSATION AGREEMENT AS TO COMPENSATION Employee _______________________________________ Employer ________________________________________________ Address ______________________________________ Address ________________________________________________ ______________________________________ ________________________________________________ _____________________________________ _______________________________________________ Insurance Carrier/Self-insurer ______________________ Third party adjuster _______________________________________ Address Address ________________________________________________ ____________________________________ ____________________________________ _______________________________________________ ____________________________________ _______________________________________________ The above have reached an agreement in regard to compensation for the injury sustained by said employee and submit the following statement of facts relative thereto: Date of Injury ________________________________________ Date Disability Began _____________________________ Cause/Place of Accident _____________________________________________________________________________________ Nature/Part of Body ________________________________________________________________________________________ _________________________________________________________________________________________________________ Probable Length of Disability (if known) ________________________________________________________________________ The terms of this agreement under the above facts are as follows: This agreement is for (check all that apply) _________________ Total Disability __________________Temporary Partial Disability __________ Permanent Partial Disability ____________ Disfigurement ____________ Commutation ____________ Medical Only _______ Salary in Lieu of Workers’ Compensation That the said ______________________________________________________________ shall receive compensation at the rate of $__________________ per week based upon an average weekly wage of $ ________________ and that said compensation shall be payable _______ weekly _________ bi-weekly _______ monthly _______ other (specify) from and including the _________ day of ___________________ month ____________ year until terminated in accordance with the provisions of the Workers’ Compensation See reverse side Law of the State of Delaware. BENEFITS FOR TOTAL/PARTIAL DISABILITY, (LOST WAGES) SHALL REQUIRE YOU TO ADVISE THE NAMED American LegalNet, Inc. www.FormsWorkflow.com CARRIER/SELF-INSURER/THIRD PARTY ADJUSTER OF ANY CHANGES IN EMPLOYMENT STATUS AND/OR DISABILITY. FAILURE TO NOTIFY A CHANGE IN STATUS IS PUNISHABLE PURSUANT TO TITLE 18, DELAWARE CODE, CHAPTER 24, AND/OR TITLE II, DELAWARE CODE, SECTION 913. Witness ________________________________________ (signature) Employee _______________________________________________ (signature) Address ________________________________________ ________________________________________ Adjuster/Attorney _________________________________________ (signature) Phone number ________________________________________ Date of agreement _______________________________________ For Accounting Use Only: Approved by ____________________________________________ Date of Approval _________________________________________ Document No. 60-07-01-01-12/97 American LegalNet, Inc. www.FormsWorkflow.com