BEFORE THE WORKERS' COMPENSATION BOARD OF THE STATE OF OREGON In the Matter of the Compensation ) ) ) ) ) ) ) ) CDA No. WCB Case No. Claim No. DOI WCD File No. Insurer/Employer CLAIM DISPOSITION AGREEMENT of , Claimant TYPE OF RELEASE Full Partial ISSUE/BENEFIT RELEASED Temporary Disability Permanent Disability Vocational Assistance Survivor's Benefits Penalties and Attorney Fees AMOUNT OF DISPOSITION $ $ Total Due Attorney (Subject to WCB approval) Total Due Claimant METHOD OF PAYMENT (check one) Lump Sum Structured Settlement Both of the Above WAIVER OF "30-DAY" PERIOD YES NO American LegalNet, Inc. www.FormsWorkFlow.com 1. Claimant's name and address: 2. Employer's name and address: 3. Carrier's name and address: 4. Claimant's attorney's name and address 5. Employer's/Insurer's attorney's name and address: 6. The accepted conditions subject to this claim disposition agreement are: 7. This claim was first closed on: 8. The total amount (percent) of permanent disability benefits awarded on the claim is: 9. The worker has / has not ever been able to return to the work force following the industrial injury or occupational disease. 10. The worker's age is and his/her highest educational level is . The extent of vocational training (or, if the worker is deceased, the age, highest education level, and the extent of vocational training of the worker's beneficiary(ies)) is/are 11. The following is a list of occupations that the worker has performed (or, if the worker is deceased, a list of occupations that each of the deceased worker's beneficiaries has performed): 12. Pursuant to ORS 656.236, in consideration of the payment of $ by the insurer/employer, claimant releases his/her right to the following workers' compensation benefits (e.g., temporary disability, permanent disability, vocational rehabilitation and survivor's benefits): The insurer's/employer's obligation to provide these benefits is also released. [Claimant does not release his/her right to attorney fees or penalties in relation to medical services disputes arising after the date of receipt of this agreement by the Board]. 13. Out of the above consideration, claimant's attorney shall receive an attorney fee in the amount of $ a. If the attorney fee exceeds the Board's rule (OAR 438-015-0052), the extraordinary circumstances that justify this fee are . b. If the agreement is to be paid in installments beyond one year, the cost of the annuity or the present value of the agreement is $ . American LegalNet, Inc. www.FormsWorkFlow.com 14. 15. Claimant retains his/her right to medical services for the compensable injury. Claimant was given a written notice, separate from the agreement, in the form prescribed by the Board pursuant to OAR 438-009-0022. [The following notice must either be included in the claim disposition agreement or incorporated by reference into the agreement]. 16. "NOTICE TO CLAIMANT: UNLESS YOU ARE REPRESENTED BY AN ATTORNEY AND YOUR CLAIM DISPOSITION AGREEMENT INCLUDES A PROVISION WHICH WAIVES THE 30-DAY "COOLING OFF" PERIOD, YOU WILL RECEIVE A NOTICE FROM THE WORKERS' COMPENSATION BOARD OR THE ADMINISTRATIVE LAW JUDGE WHO MEDIATED THE AGREEMENT TELLING YOU THE DATE THIS AGREEMENT WAS RECEIVED BY THEM FOR APPROVAL. YOU HAVE 30 DAYS FROM THE DATE THE BOARD OR THE ADMINISTRATIVE LAW JUDGE WHO MEDIATED THE AGREEMENT RECEIVES THE AGREEMENT TO REJECT THE AGREEMENT, BY TELLING THE BOARD OR THE ADMINISTRATIVE LAW JUDGE WHO MEDIATED THE AGREEMENT IN WRITING. DURING THE 30 DAYS ALL OTHER PROCEEDINGS AND PAYMENT OBLIGATIONS OF THE INSURER/SELF-INSURED EMPLOYER, EXCEPT FOR MEDICAL SERVICES, ARE STAYED ON YOUR CLAIM. IF YOU DO NOT HAVE AN ATTORNEY, YOU MAY DISCUSS THIS AGREEMENT WITH THE BOARD IN PERSON WITHOUT FEE OR CHARGE. TO CONTACT THE BOARD, WRITE OR CALL: WORKERS' COMPENSATION BOARD, 2601 25TH STREET SE, SUITE 150, SALEM, OREGON 97302-1280, TELEPHONE: (503) 378-3308, TOLL-FREE AT 1-877-311-8061, 8:00 TO 5:00, MONDAY THROUGH FRIDAY. "YOU MAY ALSO DISCUSS THIS AGREEMENT WITH THE WORKERS' COMPENSATION OMBUDSMAN, WITHOUT FEE OR CHARGE. TO CONTACT THE OMBUDSMAN, WRITE OR CALL: WORKERS' COMPENSATION OMBUDSMAN, LABOR & INDUSTRIES BUILDING, 350 WINTER STREET NE, SALEM, OR 97310, TELEPHONE: TOLL-FREE AT 1-800-927-1271, 8:00 TO 5:00, MONDAY THROUGH FRIDAY. "YOU MAY ALSO CALL THE WORKERS' COMPENSATION DIVISION'S INJURED WORKER HOTLINE, TOLL-FREE, AT 1-800-452-0288." 17. Payment of the disposition shall be made no later than the 14th day after notice of the Board's approval has been mailed or distributed to the parties or their representatives under OAR 438-009-0030(5) and (6) by means of an order, posting on WCB's website, electronic distribution through WCB's website portal, or postcard. See OAR 438-009-0028; OAR 438-009-0030(7). On Board approval of this agreement, the following requests for hearing/review shall be dismissed: WCB Case No. 18. American LegalNet, Inc. www.FormsWorkFlow.com 19. Claimant acknowledges that he/she has reviewed the description of benefits, as described in this agreement and the informational enclosure prescribed in OAR 438-009-0022, and has had an opportunity to ask questions of his/her attorney or the insurer/employer to further understand the consequences of signing this agreement. [If parties are waiving "cooling off" period] Claimant is represented by an attorney and all parties agree to waive the "30 day" waiting period under ORS 656.236(1)(a)(C) for Board approval of the agreement. IT IS SO STIPULATED AND AGREED. 20. Claimant Claimant's Attorney Insurer/Employer Insurer's/Employer's Attorney Date Date Date Date THIS AGREEMENT IS IN ACCORDANCE WITH THE TERMS AND CONDITIONS PRESCRIBED BY THE BOARD. SEE ORS 656.236(1). ACCORDINGLY, THIS CLAIM DISPOSITION AGREEMENT IS APPROVED. AN ATTORNEY FEE PAYABLE TO CLAIMANT'S ATTORNEY ACCORDING TO THE TERMS OF THIS AGREEMENT IS ALSO APPROVED. IT IS SO ORDERED. DATED THIS _______ DAY OF __________________, 20____. _____________________________ Board Member or Administrative Law Judge Who Mediated the Agreement _____________________________ Board Member NOTICE TO ALL PARTIES: THIS ORDER IS FINAL AND IS NOT SUBJECT TO REVIEW. ORS 656.236(2). American LegalNet, Inc. www.FormsWorkFlow.com