COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : THE STATE OF NEW HAMPSHIRE Index No. DEPARTMENT OF LABOR : CONCORD NH 03301 Calendar No. : LUMP SUM SETTLEMENT AGREEMENT JUDICIAL Plaintiff(s) SUBPOENA -against- Claimant’s SS No.________________________________ : Employer’s ID No.________________________________ : (9-digit number assigned by proper Federal Agency) Insurance Carrier_________________________________ : (Number) _____________________________ with a mailing address ____________________________ : (Name . . .Claimant. or . . . . . . . . . . . . . . . . . . . .Defendant(s) . . . . . . . (Number and Street) . . . . of . . . . . . . . . Dependent) .......... City or Town of ________________________State of ___________________Zip Code ______ and ________________________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK (Name of Employer or Insurance Company) TO Office Address________________________________________________________________ (Name and Street) (City or Town) (State) hereby acknowledge they have reached a mutual resolution of the matters in dispute between them arising from an injury which occurred on ____________, _____, while the claimant was GREETINGS: (Date) was employed by ____________________________. In accordance with the provisions of you attend before WE COMMAND YOU, that all business and excuses being laid aside, you and each of (Name of Employer) , the Honorable at the Court RSA 281-A:37, the parties jointly requestat located approval of the settlement of $____________ to be paid in a County of lump room in sum. , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Social Security offset (if applicable). ___________________________________________________________________________________ ___________________________________________________________________________________ ______________________________________________________________ court and will make you liable to Your failure to comply with this subpoena is punishable as a contempt of WITNESS: on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a CLAIMANT the party ___________________________________ ___________________________________ result of your failure to comply. (Print Name) (Print Name) Witness, Honorable _______________________Date________ Court in County, day of (Signature) , one of the Justices of the ________________________Date_______ , 20 (Signature) EMPLOYER OR INSURANCE COMPANY __________________________________ below) (Attorney must sign above and type name (Authorized By and Title) ________________________Date_______ (Signature) Attorney(s) for The above request for the payment of Lump Sum Settlement is hereby approved. ________________________________________ ______________________ Commissioner or Commissioner’s Representative Date Approved Office and P.O. Address Attorney Fees and Expenses totaling $___________are hereby approved.__________ Initial Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Form No. 15WCA(10-99) Page 1 of 6 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : LUMP SUM SETTLEMENT QUESTIONNAIRE Index No. : Calendar No. RSA 281-A:37 provides that lump sum settlement agreements for at work injuries may be : JUDICIAL SUBPOENA permitted at the discretion of the Labor Commissioner or his designated representative when it Plaintiff(s) is in the best interest of all concerned. Please provide the: following information for the -againstDepartment’s consideration in reviewing the proposed lump-sum settlement. : Claimant____________________________________ Date of Birth ______________ Attained Age ______________ : Current Address________________________________________________________ Defendant(s) : ...................................................... Employer ___________________________________ Date of Injury______________ Comp Rate $___________ AWW $_____________ Carrier_____________________ THE PEOPLE OF THE STATE OF NEW YORK Claimant Attorney (if applicable)____________________________________________ TO Carrier Attorney (if applicable)_____________________________________________ Have there been any hearings at the Department? (Y)_____ or (N) _____ GREETINGS: If yes, when? __________________________________________________________ attend before WE COMMAND YOU, that all business and excuses being laid aside, you and each of you the Honorable at the Court Is there an appeal pending (Y)_____or (N)_____ What is the status of appeal?_______ located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed 1. or adjournedis theto testify and current medical witness in Please summarizeof the then What date, claimant’s give evidence as a status? this action on the part briefly, attach all current physician office notes, surgical reports, and any IME reports. (“Previously submitted” is not an acceptable answer to this question.) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. 2. What specific date of injury is being settled? Witness, Honorable , one of the Justices of the If there’s more than one date of injury and it does not involve a recurrence, a Court in day proposal must be completed and submitted. , 20 separate lump County, sum settlementof 3. (Attorney must sign What specific injury(ies) and/or condition(s) are being settled? above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Form No. 15WCA(10-99) Page 2 of 6 American LegalNet, Inc. www.USCourtForms.com , COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. 4. Has the treating physician released the claimant to work? (Y) ____ (N)_____ : Calendar No. Full-Time______________ or Part-Time _____________ Full-Duty___________ or Light-Duty_____________ : Is the claimant working? (Y) ____ or (N) ____ JUDICIAL SUBPOENA Plaintiff(s) 5. Briefly outline the claimant’s education and work history. -against- : : : 6. Are there barriers to employment? (e.g., language, non-work Defendant(s) : . . . . related .condition(s),. etc.) . .(Y). ______ .(N)_______ . . ....... ........... .... .. ....... ........... If yes, please list: THE PEOPLE OF THE STATE OF NEW YORK 7. Has a Permanent Impairment Award been previously approved by the Department? TO (Y)______ (N) _______ If not, has there been a determination of permanent impairment that is included in this settlement? (Y)______ (N) ______ If yes, please attach the supporting medical report(s). GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court 8. County ofthere any outstanding medical bills? (Y) _____ (N) ______ Are located at a) to be condition of settlement. the in room List all bills that are day of paid as a , 20 , on the , at o'clock in noon, and at any recessed b) List date, to testify remain in dispute a witness in this action onissue for formal all bills that and give evidence as and may become an the part of the or adjourned hearing at a later date. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a 9. result of youriffailure vocational rehabilitation services have been provided to the What, any, to comply. claimant? Witness, Honorable Court in County, 10. , one of the Justices of the day of , 20 What are the claimant’s vocational/employment prospects or plans? (Attorney must sign above and type name below) 11. Has application been made or is the claimant receiving Social Security Disability benefits? (Y) ______ (N) ______ Attorney(s) for If yes: a) When were they first applied for? b) When was the first payment received? Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Form No. 15WCA(10-99) Page 3 of 6 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : 12 Index No. Is a third-party action pending or anticipated? (Y) _____ (N) _____ : If yes: Calendar No. a)Is the claimant aware of the carrier’s lien on future net third : party proceeds? (Y) ______ (N) ______JUDICIAL SUBPOENA Plaintiff(s) b)Is the claimant aware of the “Holiday” provisions in the event -against: of future medical treatment? (Y) ______ (N) ______ : 13. Has a third-party settlement been approved by either the Superior Court or Department of Labor? (Y) ______ (N) _______ : If yes, attach a copy of the approval order and workers’ compensation carrier’s Defendant(s) : . . . . confirmation .of. lien. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............ . .... 14. Please check any additional issues that are applicable to this settlement and all documentation to substantiate such. attach THE PEOPLE OF THE STATE OF NEW YORK a) NH Child Support Lien ____ f) Trust or Guardianship ___ g) Second Injury Fund/Concurrent c) Third Party Settlement ____ Wages Application _________ d) Annuity Settlement and/or h) Attorney Lien(s) $___________ Payout Provisions ____ i) IRS Lien $___________ GREETINGS: e) Vocational Rehabilitation j) Mediation Expense $_________ Escrow Amount YOU, that all business and excuses being laid aside, you and each of you attend before WE COMMAND $________ k) Other (Specify)_____________ TO b) Social Security Offset ____ the Honorable at the Court 15. In regards to this date oflocated at the claimant’s representative or counsel injury, will County of continue to ,assist the claimant on follow-up medical billo'clock in the thenoon, and at any recessed hearings at in room on the day of , 20 , at Department? testify and give evidence as a witness in this action on the part of the or adjourned date, to 16. Is the claimant under any pressure by anyone to lump-sum settle his/her claim at this time? (Y) _____ (N) ______ Your failure to comply If yes, please explain. with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. 17. Witness, Honorable , one of the Justices of the Please provide the rationale and calculations that form the basis for this Court in County, day of , 20 settlement proposal. If a vocational rehabilitation plan is included in these calculations, a copy of the approved rehabilitation plan must be attached: RATIONALE: (Attorney must sign this time). (The reason why this case should be settled atabove and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Form No. 15WCA(10-99) Page 4 of 6 American LegalNet, Inc. www.USCourtForms.com , COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. CALCULATIONS: (List the actual figures for each item considered in the : Calendar No. settlement. Add them and show the TOTAL SETTLEMENT). Note: If the carrier has waived all or part of its lien in a third party settlement, the amount waived : must be included as part of the total settlement figure. For example, a payment JUDICIAL SUBPOENA Plaintiff(s) of $10,000.00 to the claimant plus the waiver of a lien $14,500 = $24,500 total -against: settlement. : : Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court I have read and understood all questions posed by this Claimant’s Affidavit: located at County of in room , on the proposal and have, no further questions as of the date of at any recessed day of 20 , at o'clock in the noon, and the lump sum as a witness or adjourned date, to testify and give evidence settlement.in this action on the part of the _____________________________ Claimant’s Signature _________________________________ Claimant’s Attorney’s Signature Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to (if applicable) the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. _____________________________ Date _________________________________ Date Witness, Honorable Court in County, day of __________________________________ , one of the Justices of the , 20 Carrier/Employer Representative Signature __________________________________ Date (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Form No. 15WCA(10-99) Page 5 of 6 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. CLAIMANT’S AFFIDAVIT : Calendar No. : JUDICIAL SUBPOENA This is to attest that I have been fully apprised of my rights under Plaintiff(s) RSA 281-A, the Workers’ -againstCompensation law. : I understand that all my injured employee rights, including, but not limited to the following : are forgone upon the Department of Labor signature on the Lump Sum Settlement. : Defendant(s) : . . . . RSA . . . . . . . . . . . . . . .Alternative .Work .Opportunities. . . . . . 281-A:23-b .......... ..... ............ RSA 281-A:25 RSA 281-A:25-a Vocational Rehabilitation Reinstatement of Employee Sustaining Compensable Injuries THE RSA 281-A:28 STATE OF NEW YORK Temporary Total Disability PEOPLE OF THE Compensation for RSA 281-A:28-a Compensation for Permanent Total Disability TO RSA 281-A:31 Compensation for Temporary Partial Disability RSA 281-A:31-a Compensation for Permanent Partial Disability RSA 281-A:32 Scheduled Permanent Impairment Award RSA 281-A:48 Review of Eligibility for Compensation, Extent of GREETINGS: Disability WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court However, pursuant to RSA 281-A:23, Medical, Hospital and Remedial Care, or RSA 281located at County of A:23-a, Managed Care, I haveday of not forgone any20 in room , on the , future at , entitlement forin the o'clock medical care in settlingrecessed noon, and at any my workers’ compensation claim.give evidence as a witness in this action on the partthird party I additionally understand that the carrier, of the or adjourned date, to testify and administrator, self-insured or employer has a right to controvert any future claims for Medical, Hospital and Remedial Care as it may relate to my claim(s) for any at-work injury if it should determine that such treatment is not reasonable or made necessary by such claims for any atYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to work injury. the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. __________________________ Witness, Honorable Date Court in County, , one of the Justices of the day of ___________________________ Witness , 20 _________________________ (Attorney must sign above and type name below) Claimant Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Form No. 15WCA(10-99) Page 6 of 6 American LegalNet, Inc. www.USCourtForms.com