Fillable Form 1.: STIPULATIONS The LHWCA, 33 USC 901 (Department of Labor)

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Form 1.: STIPULATIONS The LHWCA, 33 USC 901 (Department of Labor)

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Case Name:
Case No: OWCP No:
STIPULATIONS
The Claimant injured his/her
The injury occurred at
The injury arose out of and in the course of the worker's employment with the Employer.
There was an Employer/Employee relationship at the time of the injury(ies).
The Employer was timely notified of the injury(ies).
The claim was timely filed.
The Notice of Controversion was timely filed.
The District Director's Informal Conference was conducted
The worker's average weekly wage at time of injury(ies) was
Compensation has been paid as follows (specify whether TTD, TPD, PTD, PPD*):
Medical benefits have been paid in the total amount of
The worker has been disabled as follows (specify whether TTD, TPD, PTD, PPD*):
The LHWCA, 33 USC § 901 et seq., as amended, applies to this claim.
on
on
a.
b.
c.
d.
TYPE DATES
from to
from
from
from
to
to
to
at
at
at
at
WEEKLY COMPENSATION
RATE
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
a.
b.
c.
d.
TYPE DATES
from to
from
from
from
to
to
to
.
.
.
.
.
The worker returned to his/her usual job as a
The worker has not returned to his/her usual job.
The worker has engaged in alternative employment as follows:
OTHER
Unresolved issues to be adjudicated:
The worker reached maximum medical improvement
on
14.
on
15.
16.
17.
a.
EMPLOYER DATES
from to
at
PAY RATE
b. from to
at
18.
a.
b.
c.
d.
19.
a.
b.
c.
d.
e.
f.
g.
h.
FOR THE CLAIMANT FOR THE EMPLOYER
FOR THE DIRECTOR FOR THE CARRIER
.
.
Printed Name Printed Name
Printed NamePrinted Name
/s/
/s/
/s/
/s/
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Form 1.: STIPULATIONS The LHWCA, 33 USC 901 (Department of Labor)

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Completed 26 January 2021

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