Fillable AND ORDER APPROVING SETTLEMENT (Commonwealth of Kentucky)

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AND ORDER APPROVING SETTLEMENT (Commonwealth of Kentucky)

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BROWSE COMMONWEALTH OF KENTUCKY (KY) FORMS

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Page 1 of 5
FORM 110-I
Injury
Revised February 2020
KENTUCKY DEPARTMENT OF WORKERS’ CLAIMS
Frankfort, KY 40601
AGREEMENT AS TO COMPENSATION
AND
ORDER APPROVING SETTLEMENT
Workers’ Compensation Claim No.
IF THIS FORM IS NOT PROPERLY COMPLETED, IT WILL BE DISAPPROVED.
Every Section should be filled in. If a section is not applicable, fill in the blank with N/A.
A separate Form 110 is required for each claim number in a consolidated case.
Claimant Name
Insurer/Self-Insured/Self-Insurance Group Name
SSN/Green Card
Date of Birth
Insurer Mailing Address
Claimant Mailing Address
Insurer City, State, Zip Code
Claimant City, State, Zip Code
Other Participating Party Name
Claimant E-mail Address
Other Participating Party Mailing Address
Employer Name
Other Participating Party City, State, Zip Code
Employer Mailing Address
Employer City, State, Zip Code
INJURY
Injury Date:
Location (City, County, State):
Body part(s)
affected:
Nature of Injury(ies):
Brief description of occurrence resulting in injury:
Page 2 of 5
MEDICAL INFORMATION
Medical expenses paid: $
Date of last medical payment:
Medical expenses unpaid or contested: $
Surgery performed: (check one)
☐
Yes
☐
No
Nature of surgery:
Impairment ratings: (Attach entire medical report that provides ratings)
Date Given
Physician
%
%
%
Diagnosis or diagnoses:
Restrictions on activities – Attach most recent medical report setting forth physical restrictions.
If medical treatment is continuing, attach a copy of the executed Form 113 indicating a designated physician.
WORK INFORMATION
Type of work performed at time of injury:
Average weekly wage at time of injury: $
Date of return to work after injury:
Wages upon return to work: $
Type of work performed after injury:
Type of work performed at time of settlement:
Does plaintiff/employee qualify for increased benefits under KRS 342.730(1)(c) 1 or 2?
☐
Yes
☐
No
BENEFIT AND SETTLEMENT INFORMATION
TTD: Paid from
to
@ $
*
= $
Date
Date
Amount
# of weeks
Total
PPD/PTD: Monetary terms of settlement:
paid in lump sum, or
weekly for
weeks.
Settlement computation:
TTD*IMP RATING*AMA FACTOR*MULTIPLIER*DISC FACTOR OR # OF WKS = TOTAL
Page 3 of 5
Waiver(s):
Amount for waiver
Waiver or buyout of past medical benefits
☐
Yes
☐
No
Waiver or buyout of future medical benefits
☐
Yes
☐
No
Waiver of vocational rehabilitation
☐
Yes
☐
No
Waiver of right to reopen
☐
Yes
☐
No
MSA:
☐
Yes
☐
No
If yes, amount of Medicare Set Aside
Lump Sum
Periodic payments:
*
*
=
Amount
Frequency
Duration
Total
Total Settlement:
+
=
Income Benefits
Waivers
Total
If settlement terms provide for lump sum representing weekly benefits greater than $100, does claimant have
an adequate source of income during disability?
☐
Yes
☐
No
Source of income:
Amount: $
OTHER INFORMATION
If additional information is pertinent to settlement, explain below:
Other responsible parties against whom further proceedings are reserved:
Page 4 of 5
If waiving medical benefits, please acknowledge by signing below:
I understand that my health insurance may not cover any medical expenses for my injury and I may be held responsible
for payment of medical expenses for my injury. I understand and have been advised that medical benefits under the
Kentucky Workers Compensation Act are payable for the cure and/or relief of my work injury although possibly
subject to time limitation. I have not been promised that any entity will automatically pay for medical expenses related
to my injury. I have conferred with my treating physician about medical treatment I may require in the future and am
satisfied that the amount being paid for the waiver of future medical benefits is adequate to provide for that treatment.
Plaintiff/Claimant Signature
If not waiving medical benefits in a claim subject to 780-week benefit limit, please acknowledge by signing below:
I understand that the Defendant/Employer or its insurance carrier remains liable for reasonable and necessary medical
benefits related to my injury, but that the liability is potentially limited as explained below. The Defendant retains the
right to challenge medical treatment by filing a medical dispute. I will receive notice of such a challenge by a Motion to
Reopen and Form 112/Medical Dispute.
The Defendant’s obligation to pay medical benefits will expire 780 weeks from the date of my injury unless I have
applied for and been granted a continuation of medical benefits. The Department of Workers Claims will mail to me a
notice letter twenty-six (26) weeks before the 780-week anniversary date of my injury explaining that the Defendant’s
liability for medical benefits will expire on that date unless I successfully apply for an extension. It is my responsibility
to notify the Department of Workers Claims of any changes to my physical or electronic mailing addresses to ensure I
receive this notice letter. My application for continuation of medical benefits must be filed within 75 days prior to the
termination of the 780-week allowance for medical benefits.
Plaintiff/Claimant Signature
If not represented by an Attorney, please acknowledge by signing below:
I understand that I have a right to obtain an Attorney of my choice to review this Agreement and by signing below; I
acknowledge that I have waived that right. By waiving that right, I understand I will be held to the same standard as an
Attorney and this Agreement will be enforceable as if represented by Attorney.
Plaintiff/Claimant Signature
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Page 5 of 5
Plaintiff/Claimant Signature
Attorney or representative for claimant (Signature)
Attorney or representative for employer (Signature)
Attorney or representative for claimant (Name typed)
Attorney or representative for employer (Name typed)
Mailing Address
Mailing Address
City, State, Zip Code
City, State, Zip Code
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AND ORDER APPROVING SETTLEMENT (Commonwealth of Kentucky)

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Completed 22 December 2021

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