Form Wc-3pr-1 - Release And Settlement Of Claim Computation - 1981
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RELEASE AND SETTLEMENT OF CLAIM COMPUTATION
1. Full Amount of Settlement (See Amount on Page 1)
$
2. Expenses and Costs of Action (If any)
$
3. Expenses and Costs of Action as Percentage of Amount
Of Settlement (Divide Amount in Line 2 By Amount in Line 1)
%
EMPLOYER/CARRIER
EMPLOYEE/CLAIMANT
4. Lien
$__________
7. Employee/Claimant’s Share
$
(subtract line 4 from line 1)
5. Less: Pro Rata Share of
8. Less: Pro Rata Share of
Expenses and Costs of Action
Expenses and Costs of Action
(Percent in Line 3) of
(Percent in Line 3) of
Amount in Line 4
$__________
Amount in Line 7
$
6. Net Amount Owed
$
9. Net Amount Due
$
PROOF
Line 5 – Pro Rata Share-Employer/Carrier
$_____________
Line 6 – Net Amount Owed-Employer/Carrier
_____________
Line 8 – Pro Rata Share-Employee/Claimant
_____________
Line 9 – Net Amount Due-Employee/Claimant
_____________
Full Amount of Settlement
$
WC-3PR-1 (7-81)
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