002 002 DEPARTMENT OF LABOR & INDUSTRY BUREAU OF WORKERS222 COMPENSATION THIRD PARTY002 SETTLEMENT AGREEMENT002 EMPLOYEE SOCIAL SECURITY NUMBER OR WC ID NUMBER - - EMPLOYEE First name Last name Date of birth If deceased - Dependent/Guardian/Personal Representative First name Last name Address Address City/Town State ZIP County Telephone NOTICE: Agreement should be clearly completed (preferablytyped) and uploaded in accordance with the provisions of the EDI Implementation Guide. A copymust be sent to the employee. EMPLOYEE222S ATTORNEY Name Firm name Address Address City/Town State ZIP TelephonePA Attorney ID number DATE OF INJURY WCAIS CLAIM NUMBER - - MM DD YYYY EMPLOYER Name Address Address City/Town State ZIP County Telephone American LegalNet, Inc. www.FormsWorkFlow.com 002 002 002 CALCULATION INSTRUCTIONS employee at the time of third-party recover. third-party action. BASIC RECOVERY INFORMATION 227 Complete this section for all third-party settlements. PRESENT DISTRIBUTION OF PROCEEDS 227 Complete this section to calculate the amount of proceeds the employer is to 7.Net lien (amount employer to receive)FUTURE DISTRIBUTION OF PROCEEDS 227 Complete this section to calculate how much the employer must reimburse the Note: This section is to be completed only if the total amount of the third-party recovery (#1) is greater than the amount of the accrued workers222 compensation lien (#2). Further Matters Agreed Upon: Date of this agreement -- MM DD YYYY Employer Information Services Claims Information Services Hearing Impaired Email *380*002 Auxiliary aids and services are available upon request to individuals with disabilities. Equal Opportunity Employer/Program American LegalNet, Inc. www.FormsWorkFlow.com