FORM 110-F FATALIT Y KENTUCKY DEPARTMENT OF WORKERS’ CLAIMS Frankfort, KY 40601 January, 2005 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 filled in. If a section is not applicable, fill in the blank with N/A. ___________________________________________ Decedent Security Number ______________________________________ Insurer/Self-Insured/Self-Insurance Group ________________ _____________________ Insurer’s Address Date of Birth Social _____________________________________ City, State Zip Code Address ___________________________________________ City, State, Zip Code ___________________________________________ Employer ______________________________________ Other participating parties ______________________________________ Address Zip Code ______________________________________ City, State, Zip Code Address City, State, INJURY Date of Injury: Date of Death: ________________________ 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: $___________________ WORK INFORMATION Type of work at time of injury: ________________________________ Average weekly wage at time of injury: _________________________ BENEFIT AND SETTLEMENT INFORMATION Amount and duration of temporary total disability paid to date: $ X Per week = $_______ No. of weeks Total American LegalNet, Inc. www.FormsWorkFlow.com If death occurs within 4 years of the injury, has a lump sum payment been made to decedent’s estate per KRS 342.750(6)? ________ Amount $___________ Monetary terms of settlement: $________, to be paid as follows: ___ lump sum , ___ weekly for weeks, ____ by annuity, ___ other____ Total settlement amount: $__________________ Settlement computation: ____________________________________________________________ Proceeds of the settlement are allocated among qualifying dependents as follows: Name Date of Birth Social Security Relationship to Number Decedent Address Weekly benefit Duration Relationship of claimant (party signing settlement agreement) to decedent’s minor dependents: ________________________________________________________________________________ Is decedent survived by any minor dependents other than those listed above? _________ If so, please list below: Name Address Date of Birth Guardian/Custodial ATTACHMENTS Please attach certified copies of the following documents: 1. Death Certificate 2. Marriage License 3. Birth certificates of minor dependents OTHER INFORMATION If additional information is pertinent to settlement, explain, (Attach additional pages if necessary): American LegalNet, Inc. www.FormsWorkFlow.com Other responsible parties against whom further proceedings are reserved: _________________________ This the day of , 20___. ____________________________________ Attorney or representative for claimant (Signature) ________________________________ Claimant (Signature) ____________________________________ Attorney or representative for claimant (Name Typed) ________________________________ Attorney or representative for employer (Signature) ____________________________________ Address ________________________________ Address ____________________________________ City, State, Zip ________________________________ City, State, Zip ________________________________ Attorney for Special Fund (Div. of Workers’ Comp Funds) 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 in hereby APPROVED. This the day of , 20 . _____________________________________ Administrative Law Judge American LegalNet, Inc. www.FormsWorkFlow.com