Instructions for Completing Settlement Application Name of claimant Address of claimant County in which claimant resides Telephone number of claimant Counsel of claimant (if applicable) Name of employer where claimant was injured Address of employer where injured County where injury occurred Social security number of claimant 1. Claim number in which you are applying for the settlement 2. Date of Injury, Date of Last Exposure in the claim you are requesting settlement 3. Reason you are requesting settlement 4. Amount of settlement you are requesting 5. Describe any current treatment you may be receiving 6. Indicate if you have participated in any vocational rehabilitation plan with BrickStreet Insurance 7. Describe any prior non work-related injuries or illnesses 8. Describe any other work-related injuries or illnesses that occurred outside of West Virginia 9. All current and / or arrearage child or spousal support will be deducted from the settlement you may receive 10. All overpayments you may have with BrickStreet Insurance will be deducted from your settlement 11. Indicate if you are currently receiving Social Security, Medicaid or Medicare benefits 12. Indicate if you are eligible or will be eligible for Social Security, Medicaid or Medicare benefits within the next 30 months 13. Indicate if you are currently receiving a disability or retirement benefit, other than Social Security, from your place of employment 14. If you have any pending litigation issues with BrickStreet Insurance, please provide claim number, date of injury / date of last exposure, date of ruling and issue in litigation Signature of party requesting settlement Date completing and signing application §23-5-7 Compromise and Settlement With the exception of medical benefits for nonorthopedic occupational disease claims, the Claimant, the Employer and BrickStreet Insurance may negotiate a final settlement of any and all issues in a claim wherever the claim is in the administrative or appellate processes. §85-12-6 Issues Subject to Settlement If the claim is in the review or appellate process, all claim issues, including medical, may be settled, even though the issues may not be currently contested. These issues include, but are not limited to, temporary total disability, temporary partial disability, permanent partial disability, permanent total disability, vocational rehabilitation and any other issues within the jurisdiction of BrickStreet Insurance. American LegalNet, Inc. www.FormsWorkflow.com BI-SA 01/06 Return completed form to: Settlement Application BrickStreet Mutual Insurance P.O. Box 3151 Charleston, WV 25332 CLAIMANT EMPLOYER Name (First and Last) Name Street Address Street Address City, State, Zip City, State, Zip County County Telephone Number (include area code) Telephone Number (include area code) Social Security Number Yes No Does the claimant have counsel? (If yes, please provide name and contact information.) 1. Claim number in which you are requesting settlement: 2. Date of Injury / Date of Last Exposure (month / day / year): 3. Why do you want to settle this claim? 4. What amount are you requesting for settlement? 5. Please describe any type of treatment you are currently receiving: 6. Have you ever participated in vocational rehabilitation with BrickStreet Insurance? Yes No 7. Please indicate any prior non work-related injuries or illnesses: 8. Do you have any other work-related injuries or illnesses that occurred outside of West Virginia? If yes, please provide details: Yes No 9. Do you understand and agree that any current and / or arrearage child or spousal support orders will be deducted from the settlement you may receive from BrickStreet Yes No Insurance? (BrickStreet is required to deduct any current child or spousal support): 10. Do you understand and agree that any overpayments you may have on any BrickStreet Insurance claim will be deducted from your settlement? (BrickStreet can and will Yes No deduct any overpayment from any settlement you may be granted): 11. Are you receiving Social Security, Medicaid or Medicare benefits? Yes No If yes, please provide the following information: Social Security Monthly Amount: Begin Date: Medicare Date Benefit Began: Medicaid Date Benefit Began: 12. If you are not receiving any of the above benefits, are you now eligible or will you be eligible within the next 30 months? Yes No 13. If you are receiving a disability or retirement benefit, other than Social Security, from your place of employment, please provide the following information: Type of Benefit: Monthly Amount: Date Benefit Began: Type of Benefit: Monthly Amount: Date Benefit Began: Type of Benefit: Monthly Amount: Date Benefit Began: 14. Do you have any pending litigation issues with BrickStreet Insurance? Yes No If yes, please provide claim number, date of injury / date of last exposure, date of ruling and issue in litigation: Signature of Party Requesting Settlement BrickStreet Mutual Insurance Date P. O. Box 3151 Charleston, WV 25332-3151 American LegalNet, Inc. www.FormsWorkflow.com