Attorney Worksheet For Lump Sum Or Structured-Type Settlements
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Attorney Worksheet For Lump Sum Or Structured-Type Settlements Form. This is a Rhode Island form and can be use in Workers Compensation Court Workers Comp.
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Tags: Attorney Worksheet For Lump Sum Or Structured-Type Settlements, Rhode Island Workers Comp, Workers Compensation Court
W.C.C. # of pending cases:
__________________________
__________________________
State of Rhode Island and Providence Plantations
Workers’ Compensation Court
Providence, SC.
V.
W.C. C. #
Attorney Worksheet for Lump Sum or Structured-Type Settlements
1.
2.
3.
4.
5.
6.
Petitioner’s Name
Soc. Sec. #
XXX-XXlast 4 digits only
Date of Injury
Average Weekly Wage $
Weekly Compensation Rate $
Proposed Settlement
$
a) Has the employee, now or in the past, ever been a Medicare beneficiary or applied for Medicare
benefits? Yes______ No ______
b) Has the employee ever collected or been qualified to receive age related Social Security benefits?
Yes______ No______
7. Has the employee collected Workers’ Compensation benefits for more than 6 months?
Yes______
No______
The undersigned attorneys certify that the following documents are included in this settlement package.
1. Stipulation Assigning Petition for Settlement.
2. Original and copy of the proposed order approving petition as well as an original and copy of the
proposed final decree.
3. Legible copies of ALL agreements or decrees establishing liability and periods of disability as well as
any and all agreements and decrees for specific compensation.
4. Affidavit from employer’s attorney or statement from employer regarding settlement.
a.) Attach a copy of the letter from the attorney and or insurer advising employer of details of
proposed settlement and the right to be heard.
b.) Attach a copy of the letter from the attorney and or insurer advising employer of any potential
effect of proposed settlement on their workers’ compensation premium.
5. Copies of all Impartial Medical Examinations.
6. Statement of Treating Physician.
If the employee is still treating:
Statement must be dated within 30 days of the date of the filing of the petition.
If the employee has stopped treating:
A medical report from the physician with whom the employee last treated together with a
statement of counsel that to the best of their knowledge this is the last medical report.
7. Life Expectancy Tables.
8. Affidavit of claimant regarding CMS: Medicare and Social Security if applicable
9. A list of all treating medical providers including any and all outstanding balances due and owing.
Signature of Employee’s Attorney
Signature of Employer’s Attorney
Address and Phone Number of Employee’s Attorney
Address and Phone Number of Employer’s Attorney
Bar Number of Employee’s Attorney
Bar Number of Employer’s Attorney
Rev. 02/08
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