PETITION FOR COMMUTATION TO THE INDUSTRIAL ACCIDENT BOARD OF THE STATE OF DELAWARE SITTING IN AND FOR COUNTY Claimant vs. Employer ) ) ) ) ) ) ) ) SS# Carrier File # Carrier/Self-Insurer Name Date of Injury Case File 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 blocks(s)) Total Disability, Pursuant to §2324 Permanent Impairment, Pursuant to §2326 2nd Injury Fund, Pursuant to §2327 Medical Expenses Only Partial Disability, Pursuant to §2325 All Benefits, Except Medical Expenses All Benefits, Including Medical Expenses 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. Dated this day of A.D. 20 . Name Address Document Control #: E60-07-12-12-11 American LegalNet, Inc. www.FormsWorkFlow.com