Form 14-0015 - Checklist Full Commutation - 2005 printable pdf download

Form 14-0015 - Checklist Full Commutation - 2005

CHECKLIST

FULL COMMUTATION

THIS FORM MUST ACCOMPANY THE SETTLEMENT DOCUMENTS

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All documents must be legible.

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Originals and copies must be clearly marked.

876 IAC 4.16

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8 1/2 x 11 white paper (all documents).

876 IAC 8.7

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Self-addressed stamped envelope (adequate size with sufficient

postage). 876 IAC 4.16

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First Report of Injury must be filed.

876 IAC 6.2(2)

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Form 9 must be used (Division of Workers' Compensation form).

876 IAC 6.4

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A current Form 9 must be filled out in its entirety, and signed by all

parties, including claimant.

876 IAC 3.1(18) and 876 IAC 6.4

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Final, updated claim activity report shall be filled out in its entirety

and filed with settlement papers (calculations on the report should

be identical to the calculations on the Form 9).

876 IAC 6.2(2)

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Statement showing that the expected future need for benefits of the

type provided under section 85.27 is considered.

PREPARED BY:______________________ DATE:______________________

print or type

TELEPHONE NUMBER:__________________

14-0015 (07/05)

Form 14-0015 - Checklist Full Commutation - 2005