WEST VIRGINIA OFFICES OF THE INSURANCE COMMISSIONER REQUEST FOR SETTLEMENT REVIEW INSTRUCTIONS: Please read this entire form carefully. In accordance with the provisions of W. Va. Code §23-5-7, the Insurance Commissioner may review any workers’ compensation settlement entered into by an unrepresented claimant, and may declare any such settlement void if the Insurance Commissioner determines the settlement to be unconscionable pursuant to the criteria set forth in Title 85, Series 12 of the Code of State Regulation. If you were represented by an attorney in the settlement of your workers’ compensation claim(s), the Insurance Commissioner may NOT review or set aside the settlement. All settlements of workers’ compensation claims are presumed not to be unconscionable, and you bear the burden of proving that your settlement was unconscionable before the Insurance Commissioner may void your settlement. Criteria to be considered by the Insurance Commissioner in determining whether a settlement is unconscionable include, but are not limited to: a. b. c. d. e. f. The relative position of the parties involved in the settlement at the time the settlement was entered into; The adequacy of the bargaining position of the parties at the time the settlement was entered into; The meaningful alternatives available to the claimant at the time the settlement was entered into; The existence of specific unfair terms in the settlement agreement; The nature of the entire agreement; Whether the claimant was provided ample opportunity to read and review the settlement agreement and/or whether the settlement agreement was read to the claimant; g. Whether the claimant was not informed of his ability to obtain a lawyer to assist in the review of the agreement; h. Whether any of the material terms of the settlement agreement were not conspicuous; i. The percentage of total benefits provided for under the settlement terms which have actually been received by the claimant when the claimant requested the settlement be reviewed; and j. The time that has elapsed between the time the settlement was entered into and the time the claimant requested the settlement be reviewed. PLEASE PROVIDE THE INFORMATION REQUESTED BELOW. Attach additional sheets as necessary, and provide all of the supplemental documentation requested. Failure to provide all of the information and documentation requested may delay the processing of your request for review. NAME OF CLAIMANT: DATE OF SETTLEMENT: ADDRESS: TELEPHONE NUMBER: SOCIAL SECURITY NO.: PLEASE LIST THE CLAIM NUMBERS FOR ALL CLAIMS SETTLED UNDER THE SETTLEMENT TO BE REVIEWED. Please attach additional sheets as necessary: PLEASE ATTACH THE FOLLOWING: 1. 2. A copy of the settlement agreement(s) to be reviewed. A detailed statement explaining the reasons why you believe that the settlement agreement you entered into should be voided by the Insurance Commissioner. 3. Any additional documentation you wish to be considered in the review of your settlement. I HEREBY REQUEST that the settlement of the above claim(s) be reviewed by the Insurance Commissioner pursuant to West Virginia Code § 23-5-7 and 85 C.S.R. 12. I hereby certify that the information provided in and with this Request for Settlement Review is true and correct to the best of my knowledge. SIGNATURE: _____________________________________________ DATE: MAIL COMPLETED FORM TO: WEST VIRGINIA OFFICES OF THE INSURANCE COMMISSIONER, CONSUMER SERVICES DIVISION, P.O. BOX 50540, CHARLESTON, WV 25305-0540. YOUR REQUEST FOR SETTLEMENT REVIEW MUST BE POSTMARKED WITHIN 180 DAYS OF THE DATE OF THE SETTLEMENT TO BE REVIEWED. YOU ARE STRONGLY URGED TO SUBMIT THIS REQUEST FOR SETTLEMENT REVIEW BY CERTIFIED MAIL, SO THAT YOU WILL HAVE DOCUMENTATION PROVING THAT THE REQUEST WAS TIMELY FILED. OIC-RSR1 Rev. 06-25-2010 American LegalNet, Inc. www.FormsWorkFlow.com