"Petition for Settlement - Ptd, Injury/Od Medical Closed on an Accepted Claim" - Montana

Petition for Settlement - Ptd, Injury/Od Medical Closed on an Accepted Claim is a legal document that was released by the Montana Department of Labor and Industry - a government authority operating within Montana.

Form Details:

  • The latest edition currently provided by the Montana Department of Labor and Industry;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Labor and Industry.

ADVERTISEMENT
ADVERTISEMENT

Download "Petition for Settlement - Ptd, Injury/Od Medical Closed on an Accepted Claim" - Montana

Download PDF

Fill PDF online

Rate (4.5 / 5) 15 votes
BEFORE THE DEPARTMENT OF LABOR & INDUSTRY
Employment Relations Division
PETITION FOR SETTLEMENT
(Permanent Total Disability)
Claimant
INJURY/OCCUPATIONAL DISEASE
MEDICAL BENEFITS CLOSED BY SETTLEMENT
ON AN ACCEPTED CLAIM
Employer
Insurer’s Primary Claim #:
Additional Claims:
Insurer
ACN #(s):
The claimant suffered an injury arising from a work-related accident or occupational disease occurring
on
. The insurer accepted liability for the claim(s).
The claimant and insurer have agreed to settle all compensation payments due the claimant under the
Workers’ Compensation/Occupational Disease Acts. The claimant has agreed to accept the lump sum of:
($
). Paid by the Insurer
The settlement amount shall be paid in a lump sum in addition to all sums previously paid by the insurer,
unless otherwise indicated in this Petition.*
The basis for settlement of this claim is that the claimant is permanently and totally disabled as defined in the
Acts. This settlement is based on the claimant’s total disability benefit rate after the rate has been reduced as
a result of the offset taken against the claimant’s social security disability benefits, if any.
The claimant and insurer petition the Department of Labor & Industry for approval of this settlement allowing
the claim to be fully and finally closed. Coverage for medical benefits are closed by this settlement.
The claimant, in signing and submitting this Petition to the Department of Labor & Industry, further
understands that if this Petition is approved, this insurer is forever released from payment of compensation,
medical and hospital benefits under the Workers’ Compensation and Occupational Disease Acts for the
claim(s) specified above. The claimant understands this Petition represents a settlement and, if approved,
cannot be reopened by the Department.
*Special Provisions:
Vocational Rehabilitation Provisions:
I understand and acknowledge this settlement will end all workers’ compensation coverage for medical
care for the claim(s) included above and my medical benefits will terminate. I further understand this
settlement of medical benefits may or may not result in secondary payers, such as Medicare, Medicaid,
or health insurers, denying coverage for medical expenses for condition(s) related to the claims
included above.
_____________________________
___________________________
Claimant’s Signature
Date Signed
Witness Signature
Claimant’s Address:
Street/PO Box:
City:
State:
Zip Code:
Subsequent Injury Fund Certified
Yes
NO
The
concurs and joins in the Petition for Settlement.
Insurer Authorized Representative
Date
Order
The Department of Labor & Industry hereby orders that the above settlement is approved.
Dated the
day of
,
.
___________________________________________
Signature of Authorized Department
Representative
BEFORE THE DEPARTMENT OF LABOR & INDUSTRY
Employment Relations Division
PETITION FOR SETTLEMENT
(Permanent Total Disability)
Claimant
INJURY/OCCUPATIONAL DISEASE
MEDICAL BENEFITS CLOSED BY SETTLEMENT
ON AN ACCEPTED CLAIM
Employer
Insurer’s Primary Claim #:
Additional Claims:
Insurer
ACN #(s):
The claimant suffered an injury arising from a work-related accident or occupational disease occurring
on
. The insurer accepted liability for the claim(s).
The claimant and insurer have agreed to settle all compensation payments due the claimant under the
Workers’ Compensation/Occupational Disease Acts. The claimant has agreed to accept the lump sum of:
($
). Paid by the Insurer
The settlement amount shall be paid in a lump sum in addition to all sums previously paid by the insurer,
unless otherwise indicated in this Petition.*
The basis for settlement of this claim is that the claimant is permanently and totally disabled as defined in the
Acts. This settlement is based on the claimant’s total disability benefit rate after the rate has been reduced as
a result of the offset taken against the claimant’s social security disability benefits, if any.
The claimant and insurer petition the Department of Labor & Industry for approval of this settlement allowing
the claim to be fully and finally closed. Coverage for medical benefits are closed by this settlement.
The claimant, in signing and submitting this Petition to the Department of Labor & Industry, further
understands that if this Petition is approved, this insurer is forever released from payment of compensation,
medical and hospital benefits under the Workers’ Compensation and Occupational Disease Acts for the
claim(s) specified above. The claimant understands this Petition represents a settlement and, if approved,
cannot be reopened by the Department.
*Special Provisions:
Vocational Rehabilitation Provisions:
I understand and acknowledge this settlement will end all workers’ compensation coverage for medical
care for the claim(s) included above and my medical benefits will terminate. I further understand this
settlement of medical benefits may or may not result in secondary payers, such as Medicare, Medicaid,
or health insurers, denying coverage for medical expenses for condition(s) related to the claims
included above.
_____________________________
___________________________
Claimant’s Signature
Date Signed
Witness Signature
Claimant’s Address:
Street/PO Box:
City:
State:
Zip Code:
Subsequent Injury Fund Certified
Yes
NO
The
concurs and joins in the Petition for Settlement.
Insurer Authorized Representative
Date
Order
The Department of Labor & Industry hereby orders that the above settlement is approved.
Dated the
day of
,
.
___________________________________________
Signature of Authorized Department
Representative