FORM 110 INJURY KENTUCKY DEPARTMENT OF WORKERS' CLAIMS 657 Chamberlin Avenue, Frankfort, Kentucky 40601 October 2016 Edition AGREEMENT AS TO COMPENSATION Workers' Compensation Claim No. IF THIS FORM IS NOT PROPERLY COMPLETED, THE SETTLEMENT WILL NOT BE APPROVED. Every section should be completed. If a section is not applicable, fill in the blank with N/A. Plaintiff/Employee Social Security Number/Green Card Date of Birth Mailing Address City, State, Postal Code Defendant/Employer Mailing Address City, State, Postal Code Insurer/Self-Insured/Self-Insurance Group Insurer's Mailing Address City, State, Postal Code Additional Defendant Name Additional Defendant Mailing Address Additional Defendant City, State, Postal Code Additional Other Defendant Name Additional Other Defendant Mailing Address Additional Other Defendant City, State, Postal Code INJURY Date of Injury: Where did injury occur: City/State/Postal Code: Brief description of occurrence resulting in injury: Causes of Injury: Body parts aff cted: American LegalNet, Inc. www.FormsWorkFlow.com Nature of Injury: 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 % % % % % % Restrictions on activities: Attach most recent medical report setting forth physical restrictions. Diagnoses: Date Given 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 Yes benefits? No Has the plaintiff/employee filed for Social Security Disability or Supplemental Security Income Yes No If "No", does the plaintiff/employee intend to file for Social Security Disability or Supplemental Security Income benefits? American LegalNet, Inc. www.FormsWorkFlow.com Type of work performed at time of injury: Average Weekly Wage at time of injury: $ Type of work performed after injury: Wages upon returning to work: $ Post-injury 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 income benefit 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 Yes Yes No No Amount for Waiver(s) $ $ (if yes, attach most current medical report or office note from treating physical) Waiver of vocational rehabilitation Yes No $ Waiver of right to reopen Total of Waivers: Yes No $ Monetary terms of settlement: Beginning Date Payment Amount Frequency # of Payments 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: $ 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 and I may be held responsible for payment of medical expenses for my injury. 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 without limitation as to time. I have not been promised that any entity will automatically pay for medical expenses related to my injury. 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