W.C.C. # of pending cases: __________________________ __________________________ State of Rhode Island and Providence Plantations Providence, Sc. Workers' Compensation Court vs. } W.C.C. No. Attorney Worksheet for Lump Sum or Structured-Type Settlements 1. 2. 3. 4. 5. Petitioner's Name Date of Injury Weekly Compensation Rate Total Settlement $ $ MSA Amount $ Soc. Sec # XXX-XX- last 4 digits only Counsel Fee $ 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 applied for, collected, or been qualified to receive either age related or disability related Social Security benefits? Yes No State the specific periods for which the employee has received weekly workers' compensation benefits. 6. The undersigned certifies that the following documents are included in this filing. 1. 2. A stipulation assigning this Petition for Settlement and a duly executed Petition for Settlement. Legible copies of ALL agreements, orders and decrees establishing liability and periods of disability as well as any and all agreements, orders and decrees for specific compensation. a.) If weekly or medical benefits have been paid for any "flow from" injuries, any and all agreements reflecting these conditions must be filed. An affidavit from the employer's attorney or a statement from the employer regarding the proposed settlement. a.) Attach a copy of the letter from the attorney and/or insurer advising employer of details of the proposed settlement and their right to be heard. b.) Attach a copy of the letter from the attorney and/or insurer advising the employer of the potential effect of the proposed settlement on their workers' compensation premiums. If the employer is self-insured, an affidavit signed by employer's counsel attesting that the employer has been fully advised of the details of the settlement and has no objection to same. 3. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com W.C.C. No. 4. 5. A copy of the most recent Court Impartial Medical Examination. A Statement of Treating Physician. If the employee is still treating: The statement must be dated within 30 days of the date of the filing of the petition. If the employee has stopped treating: The medical report from the physician with whom the employee last treated together with an affidavit signed by the employee or her/ his attorney that she/he is no longer treating. A Life Expectancy Table. An affidavit of the employee regarding CMS: Medicare and Social Security if applicable. A list of all treating medical providers including any and all outstanding balances due and owing. A copy of any and all notices of liens. A copy of the Structured Settlement Agreement, if applicable. A copy of the Medicare Set-Aside Agreement, if applicable. 6. 7. 8. 9. 10. 11. Signature of Employee's Attorney Address of Employee's Attorney Phone Number of Employee's Attorney Bar Number of Employee's Attorney Signature of Employer's Attorney Address of Employer's Attorney Phone Number of Employer's Attorney Bar Number of Employer's Attorney Rev. 02/14 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com