Petition For Commutation
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Petition For Commutation Form. This is a Delaware form and can be use in Workers Compensation.
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Tags: Petition For Commutation, 16, Delaware Workers Compensation,
PETITION FOR COMMUTATION
_________________
TO THE INDUSTRIAL ACCIDENT BOARD OF THE STATE OF DELAWARE
SITTING IN AND FOR
COUNTY
Employer,
vs.
Claimant.
)
)
)
)
)
)
)
)
SS#
Carrier File #
Carrier/Self-Insurer Name
Date of Injury
Hearing No.
The undersigned prays that your Honorable Board shall, after due notice of the time and
place of hearing served on all parties in interest, hear and determine the matter in accordance
with the facts and the law, and state its conclusions of fact and rulings of law.
Petition for Commutation of Benefits, Pursuant to §2358:
(Please check the appropriate block(s) )
Total Disability
Pursuant to §2324
Partial Disability
Pursuant to §2325
Permanent Partial
Pursuant to §2326
All Benefits Except
Medical Expenses
2ND Injury Fund
Pursuant to §2327
Other
Petition for Commutation of Benefits, Pursuant to §2358:
The Parties Agree to the Above Settlement Commutation to be Presented by
Stipulation to the Board. The Person Who the Parties Agreed With is
________________________________________________________________ .
The Parties Contest the Above Commutation and Request a Pre-trial Hearing.
Date this
day of
A.D. 20
.
Name
Address
Form 16
Document No. 60-07-01-90-09-01
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