BEFORE THE DEPARTMENT OF LABOR & INDUSTRY Employment Relations Division PETITION FOR SETTLEMENT INJURY/OCCUPATIONAL DISEASE MEDICAL BENEFITS RESERVED Insurer's Claim #: Claimant Employer Insurer ACN Claim#: The claimant suffered an injury arising from a work-related accident or occupational disease occurring on insurer accepted liability for the claim. The claimant and insurer have agreed to settle all compensation payments due the claimant under the Workers' Compensation/Occupational Disease Acts. The claimant shall accept the lump sum of: ($ ) paid by the Insurer. . The The settlement amount shall be paid in a lump sum in addition to all sums previously paid by the insurer, unless otherwise indicated in the special provisions section of the Petition.* The claimant and insurer petition the Department of Labor & Industry for approval of this settlement allowing the claim(s) to be fully and finally closed. For dates of injury prior to July 1, 1991, medical benefits are reserved. For dates of injury July 1, 1991 to June 30, 2011, medical benefits terminate when they are not used for a period of 60 consecutive months. For date of injury on or after July 1, 2011, medical benefits will terminate 5 years from the date of the industrial accident or occupational disease. For date of injury on or after July 1, 2011, a petition to reopen the benefits for up to 5 year after termination may be submitted to the Department of Labor and Industry, Employment Relations Division, if the condition is a direct result of the compensable injury of occupational disease and requires medical treatment in order to allow the worker to continue to work or return to work. The claimant, in signing and submitting this Petition to the Department of Labor & Industry, further understands that if this Petition is approved, this insurer is forever released from payment of compensation under the Workers' Compensation and Occupational Disease Acts for the claim(s) specified above. The claimant understands this Petition represents a settlement and, if approved, may not be reopened by the Department. *Special Provisions: Vocational Rehabilitation Provisions: ________________________ Claimant's Signature Claimant's Address: Street/PO Box: City: State: Zip Code: Subsequent Injury Fund Certified Yes ______ No ______ The ______________ Date Signed ________________________ Witness Signature concurs and joins in the Petition for Settlement. ______________________________ Insurer Authorized Representative __________ Date Order The Department of Labor & Industry hereby orders that the above settlement is approved. Dated the ___________ day of _________________, _________. ___________________________________________ Signature of Authorized Department Representative Revised 10/07/11 DLI-ERD-WCC001