Free K-WC 12 - Kansas

WORK SHEET FOR SETTLEMENTS Injury Case
Docket No. Claimant Social Security Number Respondent Insurance Carrier Date of hearing Place of hearing Heard by

Appearances: Claimant appeared by Respondent (and Insurance Co.) appeared by Workers' Compensation Fund appeared by Date of Accident Average weekly wage $ Medical evidence to be admitted: Place of Accident Compensation paid $

Medical and hospital expenses:

Basis of Settlement: (1) Compromise $ on a strict compromise of the following issues:

(2) Scheduled Injuries $ for amputation of (scheduled member) permanent partial loss of use of (scheduled member) (3) General Bodily Disability $ (as per medical report). for % permanent partial general bodily disability (as per medical report). , or %

K-WC 12 (Rev. 7-90)