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

Petition for Settlement - Ptd, Injury/Od Medical Benefits Reserved 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:

  • Released on January 1, 1997;
  • The latest edition currently provided by the Montana Department of Labor and Industry;
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BEFORE THE DEPARTMENT OF LABOR & INDUSTRY
Employment Relations Division
PETITION FOR SETTLEMENT
(Permanent Total Disability)
INJURY/OCCUPATIONAL DISEASE
MEDICAL BENEFITS RESERVED ON AN
ACCEPTED CLAIM
Claimant
Insurer’s Primary Claim #:
Additional Claim #(s):
Employer
ACN #(s):
Insurer
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 insurer shall pay to the claimant the sum of:
($
).
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. Further medical and hospital benefits are reserved by the
claimant. The claimant understands that by entering into a settlement, both the insurer and claimant agree
to assume the risk that the condition of the claimant, as indicated by reasonable investigation to date, may be
other than it appears or may change in the future. 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
injuries or diseases specified above. The claimant understands this Petition represents a settlement and, if
approved, may not be reopened by the Department.
*Special Provisions:
*Rehabilitation Provisions:
_____________________________
____________
___________________________
Claimant’s Signature
Date Signed
Witness Signature
Email Address:
Claimant’s Address:
Street/PO Box:
City:
State:
Zip Code:
The
concurs and joins in the Petition for Settlement.
______________________________
____________
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 1/97
BEFORE THE DEPARTMENT OF LABOR & INDUSTRY
Employment Relations Division
PETITION FOR SETTLEMENT
(Permanent Total Disability)
INJURY/OCCUPATIONAL DISEASE
MEDICAL BENEFITS RESERVED ON AN
ACCEPTED CLAIM
Claimant
Insurer’s Primary Claim #:
Additional Claim #(s):
Employer
ACN #(s):
Insurer
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 insurer shall pay to the claimant the sum of:
($
).
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. Further medical and hospital benefits are reserved by the
claimant. The claimant understands that by entering into a settlement, both the insurer and claimant agree
to assume the risk that the condition of the claimant, as indicated by reasonable investigation to date, may be
other than it appears or may change in the future. 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
injuries or diseases specified above. The claimant understands this Petition represents a settlement and, if
approved, may not be reopened by the Department.
*Special Provisions:
*Rehabilitation Provisions:
_____________________________
____________
___________________________
Claimant’s Signature
Date Signed
Witness Signature
Email Address:
Claimant’s Address:
Street/PO Box:
City:
State:
Zip Code:
The
concurs and joins in the Petition for Settlement.
______________________________
____________
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 1/97