FORM 110 Hearing Loss/Occupational Disease/CWP KENTUCKY DEPARTMENT OF WORKERS' CLAIMS 657 Chamberlin Avenue, Frankfort, Kentucky 40601 October 2016 Edition AGREEMENT AS TO COMPENSATION AND ORDER APPROVING SETTLEMENT Workers' Compensation Claim No. Before 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. Insurer/Self-Insured/Self-Insurance Group Insurer's Street Address City, State, Postal Code Additional Defendant Name Additional Defendant Mailing Address City, State, Postal Code Defendant/Employer Additional Other Defendant Name Mailing Address City, State, Postal Code Additional Other Defendant Mailing Address Additional Other Defendant City, State, Postal Code Additional Defendant City, State, Postal Code Plaintiff/Employee Social Security Number/Green Card Date of Birth Mailing Address HEARING LOSS OR OCCUPATIONAL DISEASE Occupational disease: Body parts affected: Cause of disease: Brief description of history of exposure: Injury Type: Length of exposure: Where did exposure occur: City/State/Postal Code: Date of last exposure: American LegalNet, Inc. www.FormsWorkFlow.com MEDICAL INFORMATION Medical expenses paid: $ Date of last medical payment: Medical expenses unpaid or contested: $ Surgery performed: Yes No Nature of surgery: Impairment ratings considered in settlement: (Attach entire medical report that provides ratings) Impairment Date Given % % % Physician Restrictions on activities: Attach most recent medical report setting forth physical restrictions. Diagnoses: Pulmonary function studies considered in settlement: (Attach entire medical report that provides ratings) FVC FEV1 Date of Study Physician Diagnosis: ILO Classification Date of Report Physician If medical treatment is continuing, attach a copy of the executed Form 113 indicating a designated physician. WORK INFORMATION Does plaintiff/employee qualify for increased benefits under KRS 342.730 (1)(c)1 or 2? Explain: Yes No American LegalNet, Inc. www.FormsWorkFlow.com Has the plaintiff/employee filed for Social Security Disability or Supplemental Security Income benefits? Yes No If `No', does the Plaintiff/Employee intend to file for Social Security Disability or Supplemental Security Income benefits? Yes No Type of work performed at last exposure: Average Weekly Wage at last exposure: $ Type of work performed after return to work: Wages upon returning to work: $ Return-to-work date: Type of work performed at time of settlement: BENEFIT AND SETTLEMENT INFORMATION Amount and duration of temporary total disability paid to date: Beginning Date End Date $ per week # of weeks Total For each lump sum or weekly income benefit payment agreed to, show your calculation below: Type Responsible party Frequency of payments Start Date Weekly payment rate Impairment Rating Grid Factor Multiplier Payment amount Number of Weeks (for income benefits) Present Value (for lump sums) Total Total of Lump Sum and Income Benefits: American LegalNet, Inc. www.FormsWorkFlow.com Are the following waivers included in the monetary settlement? Waiver or buyout of past medical benefits Waiver or buyout of future medical benefits (if yes, attach most current medical report or office note from treating physical) Waiver of vocational rehabilitation Waiver of right to reopen Monetary terms of settlement: Beginning Date (for periodic payments only) Payment Amount Frequency # of Payments Yes Yes Amount for Waiver(s) No No $ $ Yes Yes No No $ $ Total Value Total Settlement If settlement terms provide for a lump sum representing weekly benefits greater than $100, does claimant have an adequate source of income during disability? Yes No Source of income: Weekly amount: $ Does settlement include retraining incentive benefits? Yes No Yes No If yes, is claimant actively participating in instruction or training program? Name of instruction or training program (attach explanatory pages if necessary): OTHER INFORMATION If additional information is pertinent to the settlement, please explain (additional information may be attached to this form if required): Other responsible parties against whom further proceedings are reserved: American LegalNet, Inc. www.FormsWorkFlow.com If waiving medical benefits, please acknowledge by signing below: I understand that my health insurance may not cover any medical expenses for my injury, hearing loss, or occupational disease and I may be held responsible for payment of medical expenses. I further state I understand and have been advised medical benefits pursuant to the Kentucky Workers' Compensation Act are payable for the cure and/or relief of the effects of the injury, hearing loss, or occupational disease without limitation as to time. I have not been promised that any entity will automatically pay for medical expenses related to my injury, hearing loss, or occupational disease. I have conferred with my treating physician about medical treatment I may require in the future and I am satisfied that the amount being paid for the waiver of future medical benefits is adequate to provide for that treatment. Plaintiff/Employee 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. Plaintiff/Employee Signature Attorney for Plaintiff/Employee Signature Attorney for Plaintiff/Employee Name typed Mailing Address City, State, Postal Code Telephone Number Other Participating Parties: Plaintiff/Employee Signature Attorney for Defendant/Employer Signature Mailing Address City, State, Postal Code Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com