KANSAS DEPARTMENT OF LABOR www.dol.ks.gov K-WC 12 (Rev. 3-14) WORKSHEET FOR SETTLEMENTS: INJURY CASE Docket No.: Claimant: Respondent: Insurance Carrier: Date of hearing: Appearances: Claimant appeared by: Heard by: Social Security number: Place of hearing: Respondent (and insurance company) appeared by: Workers' Compensation Fund appeared by: Date of accident: Average weekly wage: $ Medical evidence to be admitted: Place of accident: Compensation paid: $ Medical and hospital expenses: Basis of Settlement: 1. Compromise $ on a strict compromise of the following issues: 2. Scheduled Injuries $ for amputation of (scheduled member) (scheduled member) , or (as per medical report). % permanent partial loss of use of 3. General Bodily Disability $ for % permanent partial general bodily disability (as per medical report). DIVISION OF WORKERS COMPENSATION 401 SW Topeka Blvd., Suite 2, Topeka, KS 66603-3105 · Phone: (785) 296-4000 American LegalNet, Inc. www.FormsWorkFlow.com