FORM 110-F FATALITY KENTUCKY DEPARTMENT OF WORKERS' CLAIMS 657 Chamberlin Avenue, Frankfort, KY 40601 October 2016 Edition AGREEMENT AS TO COMPENSATION AND ORDER APPROVING SETTLEMENT Workers' Compensation Claim No. IF THIS FORM IS NOT PROPERLY COMPLETED, THE SETTLEMENT WILL NOT BE APPROVED. Every section should be filled in. If a section is not applicable, fill in the blank with N/A. Decedent/Employee Plaintiff Relationship to Decedent/Employee Social Security Number/Green Card of Decedent/Employee Date of Birth of Decedent/Employee Mailing Address of Plaintiff City, State, Postal Code of Plaintiff Other Participating Parties Mailing Address City, State, Postal Code Insurer/Self-Insured/Self-Insurance Group Insurer's Mailing Address City, State, Postal Code Defendant/Employer Mailing Address City, State, Postal Code INJURY Date of Injury: Date of Death: Address in which injury/fatality occurred: Brief description of occurrence resulting in injury/fatality: Nature of injury(ies) including body part(s) affected: Medical expenses paid: $ Medical expenses unpaid or contested: $ MEDICAL INFORMATION Date of last medical payment: WORK INFORMATION Type of work at time of injury: American LegalNet, Inc. www.FormsWorkFlow.com Average weekly wage at time of injury: $ American LegalNet, Inc. www.FormsWorkFlow.com BENEFIT AND SETTLEMENT INFORMATION Amount and duration of temporary total disability paid to date: $ X = $ per week No. of weeks $ Total If death occurs within four (4) years of the injury, has a lump sum payment been made to decedent's estate per KRS 342.750(6)? Yes No Amount: $ Monetary terms of settlement: $ Weekly for , to be paid as follows: # weeks (if applicable) Total settlement amount: $ Settlement computation: Proceeds of the settlement are allocated among qualifying dependents as follows: Name Date of Birth Social Security Number/Green Card Relationship to Decedent Mailing Address Weekly Benefit Duration Relationship of plaintiff (party signing settlement agreement) to decedent's/employee's minor dependents: Is decedent/employee survived by any minor dependents other than those listed above? If so, please list below: Name Mailing Address, City, State, Postal Code Date of Birth Yes No Guardian/Custodial ATTACHMENTS Please attach certified copies of the following documents: 1. Death Certificate 2. Marriage License 3. Birth certificates of minor dependents American LegalNet, Inc. www.FormsWorkFlow.com OTHER INFORMATION If additional information is pertinent to settlement, explain, (Attach additional pages if necessary): Other responsible parties against whom further proceedings are reserved: This the day of , 20 . Attorney for Plaintiff Signature Plaintiff Signature Attorney for Plaintiff Name Typed Attorney or representative for Defendant/Employer Signature Mailing Address Mailing Address City, State, Postal Code City, State, Postal Code Telephone Number Telephone Number American LegalNet, Inc. www.FormsWorkFlow.com