Free K-WC 13 - Kansas

WORK SHEET FOR SETTLEMENTS
Death Case Docket No: Claimant(s): Heard By:

Respondent: Date of Hearing: Appearances: Claimant(s) Appeared By Respondent (and Insurance Co.) Appeared By Workers' Compensation Fund Appeared By Date of Accident: Place of Accident: Average Weekly Wage: $ Medical Evidence to be Admitted:

Insurance Carrier: Place of Hearing:

Date of Death:

Compensation Paid: $

Medical and Hospital Expenses:

Exhibits:

(1) Death Certificate _______________________; (2) Marriage Certificate ____________________________; (3) Birth Certificates _______________________; (4) Letters of Conservatorship _______________________.

Funeral Expenses:

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

(2)

$ $ not to exceed $

per week to surviving spouse and per week to each of . dependents

K-WC 13 (8-90)