A Form Informational Letter for an Employee who is NOT Represented by Counsel A Form Confidential Informational Letter for an Employee who is NOT Represented by Counsel and Settlement Contains a BLANKET RELEASE To: Jane Groves Senior Claims Examiner Virginia Workers' Compensation Commission Name of Employee: ________________________ Re: VWC File No._______________: I submit the following information in order to assist the Virginia Workers' Compensation Commission in determining whether to approve the proposed settlement of my pending workers' compensation claim. I understand that this information will be sealed and held in confidence by the Commission. 1. Date and nature of my injury or disease: _____________________________________________ 2. Age: __ years. 3. Family status: _____ (married, single, divorced, widowed). 4. Names and ages of all dependents: Name Age Relationship to Employee, i.e., son, daughter, or spouse 5. Are you currently working? (Yes or no) (Circle one) If yes, please provide the following: Employer Weekly Wages and Date of Return to Work 6. Please indicate the amount and source of any other income: (If you have no other income sources, please indicate "none" in the area below.) Source Amount 7. Are you able to read, write and understand the English language? (Yes or no) (Circle one). (a) If you are not literate in English, state the name of the person reading, and/or translating, and explaining the settlement papers to you. Name of Person Address Telephone Number 8. Are you currently receiving medical treatment? (Yes or no) (Circle one) Date last medical treatment ____________________ (a) Please describe the type of treatment and how often you visit your treating physician: American LegalNet, Inc. www.USCourtForms.com file:///C|/Documents%20and%20Settings/abondarenko/Des...20And%20Settlement%20Contains%20Blanket%20Release.htm (1 of 4)1/9/2006 5:58:43 AM A Form Informational Letter for an Employee who is NOT Represented by Counsel (b) Identify the doctor(s) in the space below. Name Address Telephone Number (c) Are there any outstanding medical expenses? (Yes or no) If yes, please state the name of the medical provider and the amount due. 9. Do you expect future medical expenses? (Yes or no). (Circle one) a. If you anticipate future medical expenses please describe below: Type of Medical Expense & Treatment When or How Often Anticipated 10. Do you have any other insurance that will cover your medical expenses after the settlement? (Yes or no) (Circle one). Please give the name of the company. _______________________________________________ 11. What is your intended use of the settlement proceeds? (a) If you have any outstanding debts, please itemize your major debts (over $1000.00) and the amounts, and indicate which of these debts you plan to pay from the settlement. Creditor Amount Owed Amount That You Plan to pay from the Proceeds 12. Please list all of your major financial assets (over $1000.00), including your home, land, equipment of all kinds, bank accounts, certificates of deposits, stocks, bonds and any other type of investments. Major Financial Asset Value 13. Are you receiving Social Security Disability benefits? (Yes or no) (Circle one) $_________________ If you are not receiving benefits, do you intend to apply for such benefits? (Yes or no) (Circle one) Are you currently receiving Medicare benefits? (Yes or no) (Circle one) If yes, [ ] disability or [ ] old age retirement. 14. Please explain, in your own words in the space provided below, why you believe the settlement proposal is in your best interest. American LegalNet, Inc. www.USCourtForms.com file:///C|/Documents%20and%20Settings/abondarenko/Des...20And%20Settlement%20Contains%20Blanket%20Release.htm (2 of 4)1/9/2006 5:58:43 AM A Form Informational Letter for an Employee who is NOT Represented by Counsel 15. A. 1. 2. B. ________________________________________________________________ C. ________________________________________________________________ D. _________________________________________________________________ E. F. ______________________________________________________________________ G. H. _________________________________________________________________________ I. Yes ___ No ___ Please provide the following (required): American LegalNet, Inc. www.USCourtForms.com file:///C|/Documents%20and%20Settings/abondarenko/Des...20And%20Settlement%20Contains%20Blanket%20Release.htm (3 of 4)1/9/2006 5:58:43 AM A Form Informational Letter for an Employee who is NOT Represented by Counsel Employee’s Signature: Address: Telephone Number: Date: Please return this completed form to: Jane Groves, Senior Claims Examiner Virginia Workers’ Compensation Commission 1000 DMV Drive Richmond, Virginia 23220 American LegalNet, Inc. www.USCourtForms.com file:///C|/Documents%20and%20Settings/abondarenko/Des...20And%20Settlement%20Contains%20Blanket%20Release.htm (4 of 4)1/9/2006 5:58:43 AM