"Petition for Commutation" - Delaware

Petition for Commutation is a legal document that was released by the Delaware Department of Labor - a government authority operating within Delaware.

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PETITION FOR COMMUTATION
TO THE INDUSTRIAL ACCIDENT BOARD OF THE STATE OF DELAWARE
SITTING IN AND FOR
COUNTY
)
Claimant
)
SS#
Carrier File #
)
vs.
)
)
Carrier/Self-Insurer Name
)
Employer
)
)
Date of Injury
Case File No.
The undersigned prays that your Honorable Board shall, after due notice of the time and place of
hearing served on all parties in interest, hear and determine the matter in accordance with the facts and
the law, and state its conclusions of fact and rulings of law.
Petition for Commutation of Benefits, Pursuant to §2358:
(Please check the appropriate blocks(s))
Total Disability, Pursuant to §2324
Partial Disability, Pursuant to §2325
Permanent Impairment, Pursuant to §2326
All Benefits, Except Medical Expenses
nd
Injury Fund, Pursuant to §2327
2
All Benefits, Including Medical Expenses
Medical Expenses Only
Other
Petition for Commutation of Benefits, Pursuant to §2358:
The parties agree to the above settlement commutation to be presented by stipulation to the board.
The person who the parties agreed with is
The parties contest the above commutation and request a pre-trial hearing.
Dated this
day of
A.D. 20
.
Name
Address
Document Control #: E60-07-12-12-11
PETITION FOR COMMUTATION
TO THE INDUSTRIAL ACCIDENT BOARD OF THE STATE OF DELAWARE
SITTING IN AND FOR
COUNTY
)
Claimant
)
SS#
Carrier File #
)
vs.
)
)
Carrier/Self-Insurer Name
)
Employer
)
)
Date of Injury
Case File No.
The undersigned prays that your Honorable Board shall, after due notice of the time and place of
hearing served on all parties in interest, hear and determine the matter in accordance with the facts and
the law, and state its conclusions of fact and rulings of law.
Petition for Commutation of Benefits, Pursuant to §2358:
(Please check the appropriate blocks(s))
Total Disability, Pursuant to §2324
Partial Disability, Pursuant to §2325
Permanent Impairment, Pursuant to §2326
All Benefits, Except Medical Expenses
nd
Injury Fund, Pursuant to §2327
2
All Benefits, Including Medical Expenses
Medical Expenses Only
Other
Petition for Commutation of Benefits, Pursuant to §2358:
The parties agree to the above settlement commutation to be presented by stipulation to the board.
The person who the parties agreed with is
The parties contest the above commutation and request a pre-trial hearing.
Dated this
day of
A.D. 20
.
Name
Address
Document Control #: E60-07-12-12-11