BEFORE THE DEPARTMENT OF LABOR & INDUSTRY Employment Relations Division P. O. Box 8011 Helena, Montana 59604-8011 PETITION FOR ADVANCE ________________________________________ Claimant ________________________________________ Employer ACN Claim #: ________________________________________ Insurer The claimant suffered an injury arising from a work-related accident or an occupational disease occurring on _________________________________________________. The insurer accepted liability for the claim. ___________________ PERMANENT PARTIAL DISABILITY PERMANENT TOTAL DISABILITY Insurer's Claim #: ___________________ The claimant and insurer have agreed to a lump sum advance in the amount of __________________________________________________ ($____________________). The purpose of this lump sum advance is for: ____________________________________________________ _________________________________________________________________________________________. The claimant understands the insurer may recoup this lump sum advance from any future benefits on a biweekly basis amortized at the current rate as established by the Department of Labor & Industry and/or recoup it from any award or settlement received in the future. Recoupment Provisions: _________________________________________________________________ ________________________________________________________________________________________ __________________________________ Claimant's Signature _____________________________________ Witness Signature _______________________________________ Address _____________________________________ Date Signed ________________________________________________________________________________________ City State Zip The ____________________concurs and joins in the Petition for Advance. ________________________________ ____________ Claimant's Attorney:___________________ Fee: $__________________ (Do not include costs) Insurer Authorized Representative Date Order The Department of Labor & Industry hereby orders that the above advance is approved. Dated the ___________ day of ________________________________________________________________. ___________________________________________ Signature of Authorized Department Representative Revised 5/12/09 American LegalNet, Inc. www.FormsWorkFlow.com Department Settlement Requirements from Adjusters and/or Attorneys Lump Sum Advances and Lump Sum Impairment Awards (Pre 7/1/05 only) Impairment Awards: Adjuster letter to claimant advising of entitlement and outlining award calculation Claimant's signed written request for lump sum payment If the adjuster letter to claimant advising of impairment entitlement does not include the date of the medical report issuing the impairment, we will need a copy of the impairment rating report. Lump Sum Advances Advance petition Claimant name Insurer name Employer Name Claim number Original claimant signature and address Original witness signature Original Authorized Representative signature Agency Claim Number ­ Adjusters have access to this number on the EPC system Date of injury Dollar amount of advance What the advance will be used for Recoupment language Attorney fees, if applicable American LegalNet, Inc. www.FormsWorkFlow.com