Free Form 110-F - Kentucky

FORM 110-F FATALIT Y

KENTUCKY DEPARTMENT OF WORKERS' CLAIMS Frankfort, KY 40601

January, 2005

AGREEMENT AS TO COMPENSATION AND ORDER APPROVING SETTLEMENT Workers' Compensation Claim No. ____________________
IF THIS FORM IS NOT PROPERLY COMPLETED, IT WILL BE RETURNED. Every section should be filled in. If a section is not applicable, fill in the blank with N/A.
___________________________________________ Decedent Social Security Number Address ___________________________________________ City, State, Zip Code ___________________________________________ Employer Address City, State, Zip Code ______________________________________ Other participating parties ______________________________________ Address ______________________________________ City, State, Zip Code Date of Birth ______________________________________ Insurer/Self-Insured/Self-Insurance Group ________________ _____________________ Insurer's Address _____________________________________ City, State Zip Code

INJURY Date of Injury: Date of Death: ________________________ County in which injury occurred: __________________________________________ Brief description of occurrence resulting in injury:________________________________________ ________________________________________________________________________________ Nature of injury(ies) including body part(s) affected: _____________________________________ MEDICAL INFORMATION Medical expenses paid: $ Date of last medical payment: ________________ Medical expenses unpaid or contested: $___________________ WORK INFORMATION Type of work at time of injury: ________________________________ Average weekly wage at time of injury: _________________________ BENEFIT AND SETTLEMENT INFORMATION Amount and duration of temporary total disability paid to date: $ X
Per week

= $_______
No. of weeks Total

If death occurs within 4 years of the injury, has a lump sum payment been made to decedent's estate per KRS 342.750(6)? ________ Amount $___________ Monetary terms of settlement: $________, to be paid as follows: ___ lump sum , ___ weekly for weeks, ____ by annuity, ___ other____ Total settlement amount: $__________________ Settlement computation: ____________________________________________________________ Proceeds of the settlement are allocated among qualifying dependents as follows: Name Date of Birth Social Security Number Relationship to Decedent Address Weekly benefit Duration

Relationship of claimant (party signing settlement agreement) to decedent's minor dependents: ________________________________________________________________________________ Is decedent survived by any minor dependents other than those listed above? _________ If so, please list below: Name Address Date of Birth Guardian/Custodial

ATTACHMENTS Please attach certified copies of the following documents: 1. Death Certificate 2. Marriage License 3. Birth certificates of minor dependents OTHER INFORMATION If additional information is pertinent to settlement, explain, (Attach additional pages if necessary):

Other responsible parties against whom further proceedings are reserved: _________________________ This the day of , 20___.

__________________________________________ _______________________________________ Attorney or representative for claimant (Signature) ___________________________________________ _______________________________________ Attorney or representative for claimant (Name typed) __________________________________________ Address State, Zip

Claimant (Signature)

Attorney or representative for employer ____________ ________________________ Address ________________________________________ City, City, State, Zip

ORDER APPROVING SETTLEMENT AGREEMENT IT IS ORDERED that the above Agreement as to Compensation be and the same in hereby APPROVED. This the day of , 20 .

_____________________________________ Administrative Law Judge