Form Wcb-10 - Lump Sum Settlement
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1LUMP SUM SETTLEMENT
STATE OF MAINE
WORKERS' COMPENSATION BOARD
27 STATE HOUSE STATION, AUGUSTA, MAINE 04333-0027
1. INSURER FILE NUMBER:
6. SOCIAL SECURITY NUMBER (last 4 digits):
7. WCB FILE NUMBER:
XXX-XX-
2. EMPLOYER NAME:
8. EMPLOYEE LAST NAME:
9. FIRST NAME:
10. M.I.:
3. EMPLOYER MAILING ADDRESS AND PHONE NUMBER:
11. ADDRESS-NUMBER AND STREET:
4. INSURER NAME:
12. CITY:
13. STATE: 14. ZIP:
15. HOME PHONE:
5. INSURER MAILING ADDRESS:
16. DATE OF INJURY:
17. DESCRIPTION OF INJURY:
18.
TYPE OF SETTLEMENT:
STRUCTURED SETTLEMENT
LUMP SUM SETTLEMENT
(ATTACH DOCUMENTATION)
TOTAL VALUE OF SETTLEMENT $_________________
19. PERMANENT IMPAIRMENT RATING ___________________ %
AMOUNT PAID
$_____________________________
SOURCE OF RATING _______________________________
DATE OF RATING ______________________________
20. EXPECTED FUTURE MEDICAL COSTS RELATED TO THE INJURY: $ ________________________
21. COMMENTS:
22. EMPLOYER/INSURER REPRESENTATIVE (TYPE OR
23. EMPLOYEE REPRESENTATIVE (TYPE OR PRINT):
PRINT):
RELEASE
24. EMPLOYEE/DEPENDENT:
I AM THE PERSON ENTITLED TO WORKERS’ COMPENSATION BENEFITS ON ACCOUNT OF THIS INJURY OR DEATH. I HAVE
READ THIS FORM AND ALL ATTACHMENTS. I CONSENT TO THE SETTLEMENT. WHEN THE SETTLEMENT IS APPROVED BY
THE ADMINISTRATIVE LAW JUDGE, I RELEASE THE EMPLOYER AND INSURER NAMED ABOVE FROM ALL FURTHER LIABILITY
FOR THIS INJURY, EXCEPT AS OTHERWISE APPROVED BY THE BOARD.
_________________________________
____________
____________________________________
_____________
EMPLOYEE/DEPENDENT SIGNATURE
DATE
EMPLOYEE REPRESENTAIVE SIGNATURE
DATE
25. EMPLOYER/INSURER:
THE EMPLOYER CONSENTS TO THE SETTLEMENT:
YES
NO
______________________
________________
SIGNATURE
DATE
THE INSURER CONSENTS TO THE SETTLEMENT:
YES
NO
______________________
________________
SIGNATURE
DATE
DECISION
26. THE REQUESTED SETTLEMENT (IS/IS NOT) APPROVED. THE EMPLOYER/INSURER IS ORDERED TO PAY THE
EMPLOYEE/DEPENDENT THE SETTLEMENT AMOUNT OF $ ______________________________ AND ALL
OUTSTANDING COMPENSATION OBLIGATIONS INCURRED PRIOR TO THE SETTLEMENT. PAYMENT MUST BE
MADE WITHIN 10 DAYS PURSUANT TO 39-A M.R.S.A. 324(1). THE EMPLOYER/INSURER IS ORDERED TO PAY THE
EMPLOYEE/DEPENDENT’S ATTORNEY A FEE OF $ ____________________. ALL PENDING PETITIONS BASED ON
THIS CLAIM ARE HEREBY DISMISSED.
__________________________________________
_______________________
ADMINISTRATIVE LAW JUDGE SIGNATURE
DATE
The State of Maine provides equal opportunity in employment and programs. Auxiliary aids and services are available to individuals with disabilities upon request. For assistance with this
form, contact the ADA Coordinator at the Maine Workers’ Compensation Board. Telephone: 1-888-801-9087 or TTY Maine Relay 711.
WCB-10 (eff. 1/1/13, rev. 10/15/15)
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