Reset Form AGREEMENT BETWEEN PARTIES FOR LUMP SUM PAYMENT INDIANA WORKER’S COMPENSATION BOARD 402 W. Washington Street, Room W196 Indianapolis, IN 46204-2745 State Form 34873 (R2 / 4-12) (See reverse side for fatalities) * PRIVACY NOTICE: This agency is requesting disclosure of employee’s Social Security number in accordance with IC 22-3-4-13. Federal Identification number Name of employer Social Security number * Name of employee AGREEMENT The above named employer and employee have agreed that _______________________________________________ weeks of the remainder of weekly compensation liability may be redeemed by a cash payment of a lump sum. The employee received $____________________________________ in benefits for __________________________________________ weeks of temporary total disability. An agreement has been reached regarding permanent partial impairment for ____________________________________________________________________________________________. The employer has made weekly payments in the amount of $____________________________ for ________________________________ weeks for this impairment. It is in the best interest of the employee that he/she receive a lump sum payment for the following reasons, viz: Wherefore, the employer and employee respectfully request the Board to approve the agreement for a lump sum by which ____________________ weeks of said compensation liability may be redeemed by a single cash payment of $________________________________________. Signature of employee Date signed (month, day, year) Signature of employer Date signed (month, day, year) Signature of insurance company representative Date signed (month, day, year) FOR BOARD USE ONLY Name, address, telephone number, and e-mail address of insurance company / adjuster: For Board Use Only American LegalNet, Inc. www.FormsWorkFlow.com * PRIVACY NOTICE: This agency is requesting disclosure of employee’s Social Security number in accordance with IC 22-3-4-13. Federal Identification number Name of employer Social Security number * Board number Name of employee AGREEMENT STATEMENT (Fatality) The undersigned dependents of the deceased employee and the employer respectfully request the Board’s approval on this agreement for a lump sum by which ___________________________________ weeks of said compensation liability may be redeemed by a cash payment. The deceased employee died on ____________________________________ as a result of personal injuries / illness arising out of and in the course of the employment. The dependents of the deceased employee have received _________________________ weeks of compensation at ________________________________ per week. The employer and the dependents have agreed that ____________________________ weeks of the remainder of weekly compensation liability be redeemed by a cash payment of $_______________________________________ by the employer to the dependents. It is in the best interest of the dependents that so much of the weekly compensation liability be redeemed in a lump sum for the following reasons, viz: NAME The deceased employee left surviving as the only dependents the following named person(s): WHOLLY OR ADDRESS PARTIALLY AGE RELATIONSHIP DEPENDENT (number and street, city, state, and ZIP code) Signature of dependent Date signed (month, day, year) Signature of employer Date signed (month, day, year) Signature of insurance company representative Date signed (month, day, year) Signature of parent / guardian for dependents FOR BOARD USE ONLY Name, address, telephone number, and e-mail address of insurance company / adjuster: For Board Use Only American LegalNet, Inc. www.FormsWorkFlow.com