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

Petition for Settlement - Injury/Od, Medical Benefits Closed by Settlement 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.

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BEFORE THE DEPARTMENT OF LABOR & INDUSTRY
Employment Relations Division
PETITION FOR SETTLEMENT
INJURY/OCCUPATIONAL DISEASE
MEDICAL BENEFITS CLOSED BY SETTLEMENT
Claimant
ON AN ACCEPTED CLAIM
Insurer’s Primary Claim #:
Employer
Additional Claims:
Insurer
ACN Claim#(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
($)
paid by the Insurer.
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 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. 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:
State:
Street/PO Box:
City:
Email Address:
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
BEFORE THE DEPARTMENT OF LABOR & INDUSTRY
Employment Relations Division
PETITION FOR SETTLEMENT
INJURY/OCCUPATIONAL DISEASE
MEDICAL BENEFITS CLOSED BY SETTLEMENT
Claimant
ON AN ACCEPTED CLAIM
Insurer’s Primary Claim #:
Employer
Additional Claims:
Insurer
ACN Claim#(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
($)
paid by the Insurer.
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 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. 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:
State:
Street/PO Box:
City:
Email Address:
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