Compromise And Release Agreement Summary {07-6117}

ALASKA DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT Alaska Workers' Compensation Board P.O. Box 115512, Juneau AK 99811-5512 COMPROMISE & RELEASE AGREEMENT SUMMARY AWCB Case Number Only INSTRUCTIONS: Complete and attach to the front of a compromise and release agreement submitted to the Alaska Workers' Compensation Board. This form may not be used in place of or as a compromise and release agreement. 1. Employee's Name (Last, First, Middle Initial) 4. Address City 7. Employee Attorney 9. Employer / Insurer Attorney 11. Other Party or Attorney 13. Explain Relationship to Case 15. How Did Accident Happen? 2. Insurer Claim Number 3. Injury Date 5. Social Security Number State Zip Code Telephone 8. Employer 10. Insurer 12. Other Party or Attorney 14. Explain Relationship to Case 6. Date of Birth (Age) 16. Describe Injuries: 17. Medical Reports: All medical reports in the parties' possession are attached. 18. Permanent Impairment Ratings a. of YES NO % of % % of By Dr. % of of By Dr. 20. Average Weekly Wage YES, Date: ; ; , Employee's Physician b. ; % of ; , Employee's Physician % 19. Occupation Before Injury 23. Has Employee Returned to Work? 21. Occupation After Injury NO, (Explain Why) 22. Weekly Wage 24. If Employee Returned to Work, Is He Working Now? YES NO, (Explain Why) 25. Was Employee Released for Work? Limitations: NOT RELEASED REGULAR WORK Date: MODIFIED WORK Date: 26. Is Vocational Rehabilitation Needed? NO NO YES UNKNOWN 27. Is Employee in a Vocational Rehabilitation Program? YES, (Describe) 28. Projected Vocational Rehabilitation Program Completion Date: 29. Summarize Dispute. a. Employee: b. Employer: Form 07-6117 (Rev 04/2010) CONTINUED ON BACK American LegalNet, Inc. www.FormsWorkFlow.com COMPROMISE & RELEASE AGREEMENT SUMMARY (Continued from Front) 30. Summarize Payments Made to Date or Attach a Compensation Report with a Total Payment History. a. Compensation (Complete a separate line for different rates, types or disability interruptions): TYPE FROM THROUGH WEEKS & DAYS WEEKLY RATE TOTAL AMOUNT LUMP SUM b. Medical: c. Other (Explain): Amount: TOTAL COMPENSATION: 31. Agreed Settlement. a. Compensation (Complete a separate line for different rates, types or disability interruptions): TYPE FROM THROUGH WEEKS & DAYS WEEKLY RATE TOTAL AMOUNT LUMP SUM b. Medical Benefits Released? NO YES, Amount: c. Attorney's Fees: e. REMARKS: Paid By: Employer Employe TOTAL COMPENSATION: d. Vocational Rehabilitation Benefits Released? NO YES, Amount: f. Total Agreed Settlement Amount: 32. Submitted By (Name of Person and Company or Firm): 33. Date: FOR AWCB USE ONLY 34. COMMENTS: 35. DISPOSITION: 36. By: Form 07-6117 (Rev 04/2010) APPROVE DISAPPROVE REQUEST INFORMATION RECOMMENDED HEARING 37. Date: American LegalNet, Inc. www.FormsWorkFlow.com