State Of Delaware Office Of Workers' Compensation Receipt Of Compensation Paid
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1CASE FILE NO. ______________________
CARRIER FILE NO. ___________________
STATE OF DELAWARE
OFFICE OF WORKERS’ COMPENSATION
RECEIPT OF COMPENSATION PAID
DATE ______________________
Received of ____________________________________________________________
(Insurance Carrier/Self-Insurer/Third Party Adjuster)
the sum of $ ____________________, making in all the total sum of $ ___________________
in settlement of compensation due for the ________________________________ disability of
(type)
__________________________________________________________________ which began
(employee name)
on ____________________________________, and terminated on ______________________.
(date)
(date)
__________________________
Employee Signature
__________________________
Address
__________________________
Your signature on this receipt will terminate your rights to receive the worker’s compensation benefits specified above on the
date indicated. This form is not a release of the employer’s or the insurance carrier’s workers’ compensation liability. It is
merely a receipt of compensation paid. The claimant has the right within five years after the date of the last payment to
petition the Office of Workers’ Compensation for additional benefits.
Document No. 60-07-01-02-12/97
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