CASE FILE NO. ______________________ CARRIER FILE NO. ___________________ STATE OF DELAWARE OFFICE OF WORKERS’ COMPENSATION RECEIPT OF COMPENSATION PAID DATE ______________________ Received of ____________________________________________________________ (Insurance Carrier/Self-Insurer/Third Party Adjuster) the sum of $ ____________________, making in all the total sum of $ ___________________ in settlement of compensation due for the ________________________________ disability of (type) __________________________________________________________________ which began (employee name) on ____________________________________, and terminated on ______________________. (date) (date) __________________________ Employee Signature __________________________ Address __________________________ Your signature on this receipt will terminate your rights to receive the worker’s compensation benefits specified above on the date indicated. This form is not a release of the employer’s or the insurance carrier’s workers’ compensation liability. It is merely a receipt of compensation paid. The claimant has the right within five years after the date of the last payment to petition the Office of Workers’ Compensation for additional benefits. Document No. 60-07-01-02-12/97 American LegalNet, Inc. www.FormsWorkflow.com