Form DLI-ERD-WCC001 "Petition for Settlement - Injury/Od, Medical Benefits Reserved" - Montana

What Is Form DLI-ERD-WCC001?

This is a legal form that was released by the Montana Department of Labor and Industry - a government authority operating within Montana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 7, 2011;
  • The latest edition provided by the Montana Department of Labor and Industry;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DLI-ERD-WCC001 by clicking the link below or browse more documents and templates provided by the Montana Department of Labor and Industry.

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Download Form DLI-ERD-WCC001 "Petition for Settlement - Injury/Od, Medical Benefits Reserved" - Montana

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BEFORE THE DEPARTMENT OF LABOR & INDUSTRY
Employment Relations Division
PETITION FOR SETTLEMENT
Claimant
INJURY/OCCUPATIONAL DISEASE
MEDICAL BENEFITS RESERVED
Insurer’s Primary Claim #:
Employer
Additional Claims
Insurer
ACN Claim#:
The claimant suffered an injury arising from a work-related accident or occupational disease occurring on
.
The insurer accepted liability for the claim. The claimant and insurer have agreed to settle all compensation payments
due the claimant under the Workers’ Compensation/Occupational Disease Acts. The claimant shall 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 the special provisions section of the Petition.*
The claimant and insurer petition the Department of Labor & Industry for approval of this settlement allowing the claim(s)
to be fully and finally closed. For dates of injury prior to July 1, 1991, medical benefits are reserved. For dates of injury
July 1, 1991 to June 30, 2011, medical benefits terminate when they are not used for a period of 60 consecutive
months. For date of injury on or after July 1, 2011, medical benefits will terminate 5 years from the date of the industrial
accident or occupational disease. For date of injury on or after July 1, 2011, a petition to reopen the benefits for up to 5
years after termination may be submitted to the Department of Labor and Industry, Employment Relations Division, if the
condition is a direct result of the compensable injury or occupational disease and requires medical treatment in order to
allow the worker to continue to work or return to work. 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 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, may not be
reopened by the Department.
*Special Provisions:
Vocational Rehabilitation Provisions:
________________________
________________________
Claimant’s Signature
Date Signed
Witness Signature
Email Address:
Claimant’s Address:
Street/PO Box:
City:
State:
Zip Code:
Subsequent Injury Fund Certified
The
concurs and joins in the Petition for Settlement.
Yes
No
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
Revised 10/07/11
DLI-ERD-WCC001
BEFORE THE DEPARTMENT OF LABOR & INDUSTRY
Employment Relations Division
PETITION FOR SETTLEMENT
Claimant
INJURY/OCCUPATIONAL DISEASE
MEDICAL BENEFITS RESERVED
Insurer’s Primary Claim #:
Employer
Additional Claims
Insurer
ACN Claim#:
The claimant suffered an injury arising from a work-related accident or occupational disease occurring on
.
The insurer accepted liability for the claim. The claimant and insurer have agreed to settle all compensation payments
due the claimant under the Workers’ Compensation/Occupational Disease Acts. The claimant shall 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 the special provisions section of the Petition.*
The claimant and insurer petition the Department of Labor & Industry for approval of this settlement allowing the claim(s)
to be fully and finally closed. For dates of injury prior to July 1, 1991, medical benefits are reserved. For dates of injury
July 1, 1991 to June 30, 2011, medical benefits terminate when they are not used for a period of 60 consecutive
months. For date of injury on or after July 1, 2011, medical benefits will terminate 5 years from the date of the industrial
accident or occupational disease. For date of injury on or after July 1, 2011, a petition to reopen the benefits for up to 5
years after termination may be submitted to the Department of Labor and Industry, Employment Relations Division, if the
condition is a direct result of the compensable injury or occupational disease and requires medical treatment in order to
allow the worker to continue to work or return to work. 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 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, may not be
reopened by the Department.
*Special Provisions:
Vocational Rehabilitation Provisions:
________________________
________________________
Claimant’s Signature
Date Signed
Witness Signature
Email Address:
Claimant’s Address:
Street/PO Box:
City:
State:
Zip Code:
Subsequent Injury Fund Certified
The
concurs and joins in the Petition for Settlement.
Yes
No
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
Revised 10/07/11
DLI-ERD-WCC001