KENTUCKY OFFICE OF WORKERS’ CLAIMS Frankfort, KY 40601 FORM 110-O HRNG LOSS/ OCC DIS 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 Social Security Number __________________________________________ Insurer’s Address Date of Birth ____________________________________________ Address __________________________________________ City, State Zip Code ____________________________________________ City, State, Zip Code ____________________________________________ Employer ___________________________________________ Other participating parties Address __________________________________________ Address City, State, Zip Code __________________________________________ City, State, Zip Code HEARING LOSS OR OCCUPATIONAL DISEASE : INJURIOUS EXPOSURE Occupational disease: Cause of disease: ___________________________ Date of last exposure: County in which exposure occurred: _____________ Brief description of history of exposure _______________________________________________ _______________________________________________________________________________ Body part(s) affected: Length of exposure: _______________________ 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. Diagnosis or diagnoses:____________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com If medical treatment is continuing, attach a copy of the executed Form 113 indicating a designated physician. Page 2 of 4 WORK INFORMATION Type of work at last exposure:_______________________________________________________ Average weekly wage at time of last exposure: $_________Date of return to work: _____________ Wages upon return to work: $___________ Type of work performed after return: ______________ 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 ________ @ $ ________*_______ =$________ (MM/DD/YR) Monetary terms of settlement: __ (MM/DD/YR) Amount # of wks Total , paid in lump sum:_____, or weekly for ______weeks Settlement computation: ___________________________________________________________ TTD*IMP RATING*AMA FACTOR*RTW FACTOR*DISC FACTOR OR # OF WKS = TOTAL 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 Yes Yes Yes No No No No Amount for waiver ______________ ______________ ______________ ______________ Does settlement include Medicare Set Aside? Yes No If yes, amount of Medicare Set Aside:_____________ Lump Sum Periodic payments: _________*________*________ = _________ Amount Frequency Duration Total Other: Attach explanation 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: $____________________ Does settlement include retraining incentive benefits? Yes No If yes, is claimant actively participating in instruction or training program? Yes No Name of instruction or training program (Attach additional pages if necessary):_________________ ________________________________________________________________________________ OTHER INFORMATION 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 4 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) ___________________________________________ __________________________________________ Address ___________________________________________ __________________________________________ City, State, Zip Claimant (Signature) Attorney or representative for employer Addre ss 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. American LegalNet, Inc. www.FormsWorkflow.com This the day of , 20 . _________________________________ Administrative Law Judge Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com