KENTUCKY OFFICE OF WORKERS’ CLAIMS Frankfort, KY 40601 FORM 110-I INJURY Revised July, 2006 AGREEMENT AS TO COMPENSATION AND ORDER APPROVING SETTLEMENT Workers’ Compensation Claim No. ____________________ IF THIS FORM IS NOT PROPERLY COMPLETED, IT WILL BE RETURNED. Every section should be completed. If a section is not applicable, fill in the blank with N/A. ________________________________ ________________________________ Claimant Insurer/Self-Insured/Self-Insurance Group __ Date of Birth __________________________________________ Insurer’s Address ___________________________________________ Address __________________________________________ City, State, Zip Code Social Security Number ___________________________________________ City, State, Zip Code ___________________________________________ Employer __________________________________________ Other participating parties ____________________________________________ Address __________________________________________ Address City, State, Zip Code __________________________________________ City, State, Zip Code INJURY Date: County in which injury occurred:____________________________ Brief description of occurrence resulting in injury:________________________________________ ________________________________________________________________________________ Nature of injury(ies) including body part(s) affected:______________________________________ MEDICAL INFORMATION Medical expenses paid: $ Date of last medical payment: ________________ Medical expenses unpaid or contested: $________________________________________________ Surgery performed (Circle one): Yes No Nature of surgery:__________________________ Impairment ratings: (Attach entire medical report that provides ratings) Date Given Physician % ________________________________ % ________________________________ % ________________________________ Restrictions on activities -- Attach most recent medical report setting forth physical restrictions. Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com Diagnosis or diagnoses:______________________________________________________________ If medical treatment is continuing, attach a copy of the executed Form 113 indicating a designated physician. WORK INFORMATION Type of work performed at time of injury: ______________________________________________ Average weekly wage at time of injury: $ Date of return to work after injury: __________ Wages upon return to work: $ Type of work performed after injury:_________________ Type of work performed at time of settlement: ___________________________________________ BENEFIT AND SETTLEMENT INFORMATION If consolidated Claims, indicate amount for each Claim separately: Temporary total disability paid from ________ to ________ @ $_________*_______= $_________ Date Date Amount # wks Total Monetary terms of settlement: _____________ paid in lump sum ____, or weekly for ________ # of weeks Settlement computation: _______________________________________________________________ TTD * IMP. RATING *AMA FACTOR * RTW FACTOR * DISC. FACTOR OR # of WKS = TOTAL Amount for Waiver(s) Please circle: Waiver or buyout of past medical benefits Waiver or buyout of future medical benefits Waiver of vocational rehabilitation Waiver of right to reopen Yes No Yes No Yes No Yes No __________ __________ __________ __________ Does settlement include Medicare Set Aside? Yes No If yes, amount of Medicare Set Aside: ________ Lump Sum Periodic Payments: _________* __________*__________ Amount Frequency Duration Other: Attach explanation = ___________ Total If settlement terms provide for lump sum representing weekly benefits greater than $100, does claimant have an adequate source of income during disability? Yes No Source of income: Amount: $___________________________ OTHER INFORMATION Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com If additional information is pertinent to settlement, explain, (Attach additional pages if necessary): _____________________________________________________________________________________ _____________________________________________________________________________________ Other responsible parties against whom further proceedings are reserved: __________________________ Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com If waving medical benefits, please acknowledge by signing below: I understand that my health insurance may not cover any medical expenses for my injury and I may be held responsible for payment of medical expenses for my injury. ________________________________ Claimant (Signature) If not represented by an Attorney, please acknowledge by signing below: I understand that I have a right to obtain an Attorney of my choice to review this Agreement and by signing below I acknowledge that I have waived that right. By waiving that right, I understand I will be held to the same standard as an Attorney and this Agreement will be enforceable as if represented by Attorney. ___________________________________________________________________________ Claimant (Signature) __________________________________________ _______________________________________________ Attorney or representative for claimant (Signature) __________________________________________ _______________________________________________ Attorney or representative for claimant (Name typed) Claimant (Signature) Attorney or representative for employer __________________________________________ _______________________________________________ Address Address _______________________________________________ City, State, Zip City, State, Zip ______________________________________________ Attorney for Special Fund (Div. or Workers’ Comp Funds) This the day of , 20 . DO NOT WRITE OR MARK BELOW THIS LINE ORDER APPROVING SETTLEMENT AGREEMENT IT IS ORDERED that the above Agreement as to Compensation be and the same is hereby APPROVED. This the day of , 20 . Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com Administrative Law Judge Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com